Skip to content
INTAKE FORM
1.
What is your first and last name? (NOT your loved one's name)
2.
What number can we call you on to discuss the intake form?
3.
What is your email address?
4.
Do you want a Live-In or Live-Out Caregiver?
Live-In
Live-Out
Live-In OR Live-Out
Comments
5.
How many days a week does your loved one need care?
All 7 days
Monday - Friday
Only The Weekend
Other - please explain
6.
How many hours a day does your loved one need care? Which hours/days?
7.
In which location (city, state, zip code)?
8.
Is this a long term position?
For sure, one year or longer
Less than a year
6 months
Less than 6 months
Comments
9.
How is your loved one related to you?
Mother
Father
Other (please specify)
10.
How old is your loved one
11.
Does your loved one have dementia?
No dementia
Slight
Moderate (please explain more below)
Advanced (please explain more below)
Comments
12.
Can your loved one become aggressive?
Not agressive
Yes, agressive (please explain below)
Comment
13.
Is your loved one mobile (he/she can stand up and take a few steps without assistance)?
Yes, mobile
Not mobile (please comment on his/her mobility issues. Will there be lifting involved (on the part of the caregiver)?
Comment
14.
Does the caregiver need to be stronger than average (in order to work with your loved one)?
Does not need to be stronger than average
Must be stronger than average
Comment
15.
Do you prefer a male or female caregiver? Or it doesn't matter?
Female
Male
Open to either one
Comment
16.
Does your loved one use the toilet or diapers?
Only uses the toilet
Usually uses the toilet but diapers are used in case of accidents
Usually uses diapers but sometimes the toilet
Only uses diapers
Comment
17.
Does your loved one sleep throughout the night? We are trying to assess whether the caregiver has to wake up at night to help your loved one...
Generally, my loved one does NOT need any help during the night
My loved one wakes up only once a night and needs help (but only briefly)
My loved one wakes up more than once a night and needs help (please explain more below)
Comment
18.
Does the caregiver need to have a driver's license to drive your loved one?
No, the caregiver does not need to drive
This is just a preference so I am open to interviewing all caregivers
Yes, this is an absolute must! (please explain more below and let us know if you OWN a car, for the caregiver to drive)
Comment
19.
Will the caregiver have their own room or own personal space?
Own room WITH personal bathroom
Own room WITHOUT personal bathroom
Own personal space (please explain more below)
I want a Live-Out caregiver - so it does not matter
Comment
20.
Does your loved one live alone?
Lives alone
Lives with others (please explain below, who else lives in the house?)
Comment
21.
Are there any pets in the home?
No pets
Yes, there are pets (please explain more below - what kind of pets? How many? Will the caregiver be responsible for them at all? How?)
Comment
22.
How do you prefer to pay the caregiver?
Check or Cash or Direct Deposit - it doesn't matter
Only check or direct deposit
Only cash
Comment
23.
Do you have long term care insurance that will be reimbursing you?
No LTC
Yes, LTC (please explain more below - are there any requirements from your insurance such as certifications etc?)
Comment
24.
Will you apply for Medicaid?
Yes, applying for Medicaid
Not applying for Medicaid
Might apply for Medicaid
Already has Medicaid
Comment
25.
Is your loved one on hospice or going to be on hospice?
Not on hospice
Might go on hospice
Already on hospice
Comment
26.
Please list your loved one's serious health conditions
27.
Does your loved one have an easy personality to work with?
Yes, easy
Not easy - please explain more below
Comment
28.
What are you looking for in a caregiver?
29.
What kind of caregiver would be a good match or a good fit for your loved one?
30.
What kind of caregiver would NOT be a good fit for your loved one?
31.
When do you need your caregiver to start working?
32.
Do you have plans to issue a W2 or 1099 or any other such form to the caregiver?
No
Maybe
Yes
Comment
33.
Is there public transportation that is within walking distance to your loved one's home? If so, which train/bus? Which stop? How long is the walk?
There is a train
There is a bus
No
Comment