Back Let's Begin! Care Needs Schedule Caregiver Caretaker Review & Submit Tell us about your who needs care? What is your address? Address 1 Address 2 City State Zip Code Your who needs care?'s address Address 1 Address 2 City State Zip Code What daily activities does your who needs care? need help with? Bathing Dressing and Grooming Toileting Medication Reminder Meal Prep Exercise Transportation Housekeeping Companionship Any special care concerns or medical conditions? ALS Alzheimer's Disease Arthritis Blood Disorders Cancer Recovery Cardiovascular Disorders COPD Dementia Depression Diabetes Gastrointestinal Disorders Hearing Disorders HIV/AIDS Home Health Care Hospice Care Multiple Sclerosis Neurological Disorders Orthopedic Care Palliative Care Parkinson's Disease Post Surgery Recovery Renal and Urological Disorders Respiratory Disorders Skin Disorders Stroke Trachetomy/Ventilation Vision and Eye Disorders What financial resources will be used for the caregiving services? Savings Private insurance Long term insurance Medicare Medicaid Who will be billed for the services? Children Parents Mother Father Others Next Tell us about the care schedule When would you like care to begin? How long do you expect to need care? Less than 1 month 1-3 months 4-6 months More than 6 months Not sure Is this a recurring visit? No Yes Would you like to confirm the visit in advance? No Yes Please specify when you need care M T W T F S S Monday Start Time: 01 02 03 04 05 06 07 08 09 10 11 12 00 15 30 AM PM End Time: 01 02 03 04 05 06 07 08 09 10 11 12 00 15 30 AM PM Tuesday Start Time: 01 02 03 04 05 06 07 08 09 10 11 12 00 15 30 AM PM End Time: 01 02 03 04 05 06 07 08 09 10 11 12 00 15 30 AM PM Wednesday Start Time: 01 02 03 04 05 06 07 08 09 10 11 12 00 15 30 AM PM End Time: 01 02 03 04 05 06 07 08 09 10 11 12 00 15 30 AM PM Thursday Start Time: 01 02 03 04 05 06 07 08 09 10 11 12 00 15 30 AM PM End Time: 01 02 03 04 05 06 07 08 09 10 11 12 00 15 30 AM PM Friday Start Time: 01 02 03 04 05 06 07 08 09 10 11 12 00 15 30 AM PM End Time: 01 02 03 04 05 06 07 08 09 10 11 12 00 15 30 AM PM Saturday Start Time: 01 02 03 04 05 06 07 08 09 10 11 12 00 15 30 AM PM End Time: 01 02 03 04 05 06 07 08 09 10 11 12 00 15 30 AM PM Sunday Start Time: 01 02 03 04 05 06 07 08 09 10 11 12 00 15 30 AM PM End Time: 01 02 03 04 05 06 07 08 09 10 11 12 00 15 30 AM PM Back Next What qualities would you like in a caregiver? What gender caregiver would you prefer? No Preference Male Female Where will the caregiver live? In his/her own home (Live-out) In my who needs care?'s home (Live-in) Our caregiver speaks these languages… ASL Arabic Armenian Cantonese Chinese Mandarin English French German Greek Gujarati Hebrew Hindi Hmong Italian Japanese Korean Persian Polish Portuguese Russian Spanish Tagalog Urdu Vietnamese What certifications should the caregiver have? CNA CPR HHA LPN PCA RN First Aid Other (Specify) 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? On time Keeps things neat and clean Organized Detail oriented What are the three most important social skills you'd like in a caregiver? Follows directions Has empathy Fun and outgoing Good listener Patient Team player Talkative Speaks clearly What are the two most important learning skills you'd like in a caregiver? Educated Quick learner Smart Which of the following mobility requests will your who needs care? need assistance with? Catheter Care Hoyer Lift Pivot Transfer Total Bed Rest Use Gait Belt I see my who needs care? as... Extraverted, enthusiastic Disagree strongly Disagree moderately Neither agree nor disagree Agree moderately Strongly agree Critical, quarrelsome Disagree strongly Disagree moderately Neither agree nor disagree Agree moderately Strongly agree Dependable, self-disciplined Disagree strongly Disagree moderately Neither agree nor disagree Agree moderately Strongly agree Anxious, easily upset Disagree strongly Disagree moderately Neither agree nor disagree Agree moderately Strongly agree Open to new experiences, complex Disagree strongly Disagree moderately Neither agree nor disagree Agree moderately Strongly agree Reserved, quiet Disagree strongly Disagree moderately Neither agree nor disagree Agree moderately Strongly agree Sympathetic, warm Disagree strongly Disagree moderately Neither agree nor disagree Agree moderately Strongly agree Disorganized, careless Disagree strongly Disagree moderately Neither agree nor disagree Agree moderately Strongly agree Calm, emotionally stable Disagree strongly Disagree moderately Neither agree nor disagree Agree moderately Strongly agree Conventional, uncreative Disagree strongly Disagree moderately Neither agree nor disagree Agree moderately Strongly agree Does your who needs care? like to read or listen to audio books? Read Audio Both None Which materials does your who needs care? like to read or listen to? Books Magazines Newspapers Mysteries Romance Science fiction Biography Poetry Science Which ways do your who needs care? like to keep up with the news? Conversation Discussions with another person Group discussions Listen to the radio Use the computer Watch or listen to TV Read magazines Read newspaper Does your who needs care? like to (able to) go outside? No Yes How many times does your who needs care? like to go outside in a week? Daily 2-3 times a week 4-5 times a week Once a week Activities your who needs care? needs to do outside? Arranging transportation Providing transportation to an appointment Completing shopping trip or grocery delivery Other What is your who needs care?'s religious background? Catholic Jewish Protestant Buddhism Hindu Jain Muslim Sikh Other Which religious services or practices does your who needs care? like? Observe dietary requirements Kosher foods No meat on Fridays Vegetarian Read / study the Torah / Bible / Koran / Other Pray / meditate Visits from clergy, pastor, priest, rabbi Attend religious services Listen to services on a tape / radio Watch service on TV Back Next 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. Disagree strongly Disagree moderately Neither agree nor disagree Agree moderately Strongly agree You feel stressed or strained when are around your who needs care?. Disagree strongly Disagree moderately Neither agree nor disagree Agree moderately Strongly agree You could do a better job in caring for your who needs care?. Disagree strongly Disagree moderately Neither agree nor disagree Agree moderately Strongly agree Overall, how burdened do you feel in caring for your who needs care?? Not burdened at all Somewhat burdened Very burdened Back Next Complete the information below and click the Done button below to complete your care request. Title Your caregiver rate: Your information First name Last name Email address Phone Location: Your who needs care?'s information First name Last name Location: Back Done Done 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. Click here to view recommended caregivers