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Tell us about your who needs care?

What is your address?

Your who needs care?'s address

What daily activities does your who needs care? need help with?

Any special care concerns or medical conditions?

What financial resources will be used for the caregiving services?

Who will be billed for the services?

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Tell us about the care schedule

When would you like care to begin?

How long do you expect to need care?

Is this a recurring visit?

Would you like to confirm the visit in advance?

Please specify when you need care

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    End Time:
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What qualities would you like in a caregiver?

What gender caregiver would you prefer?

Where will the caregiver live?

Our caregiver speaks these languages…

What certifications should the caregiver have?

What kind of qualities would you like your caregiver to have:

What are the two most important organizational skills you'd like in a caregiver?

What are the three most important social skills you'd like in a caregiver?

What are the two most important learning skills you'd like in a caregiver?

Which of the following mobility requests will your who needs care? need assistance with?

I see my who needs care? as...

Extraverted, enthusiastic

Critical, quarrelsome

Dependable, self-disciplined

Anxious, easily upset

Open to new experiences, complex

Reserved, quiet

Sympathetic, warm

Disorganized, careless

Calm, emotionally stable

Conventional, uncreative

Does your who needs care? like to read or listen to audio books?

Which materials does your who needs care? like to read or listen to?

Which ways do your who needs care? like to keep up with the news?

Does your who needs care? like to (able to) go outside?

How many times does your who needs care? like to go outside in a week?

Activities your who needs care? needs to do outside?

What is your who needs care?'s religious background?

Which religious services or practices does your who needs care? like?

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How are you feeling about your who needs care?'s current state of care?

Your who needs care? asks for more help than he/she needs.

You feel stressed or strained when are around your who needs care?.

You could do a better job in caring for your who needs care?.

Overall, how burdened do you feel in caring for your who needs care??

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Complete the information below and click the Done button below to complete your care request.

Your caregiver rate:

Your information

Location:

Your who needs care?'s information

Location:
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Thank you for telling us about your care needs!
Please check your email for confirmation of your request.
A Care Advisor will be in touch soon to assist you.

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