INTAKE FORM Question Title * 1. What is your first and last name? (NOT your loved one's name) Question Title * 2. What number can we call you on to discuss the intake form? Question Title * 3. What is your email address? Question Title * 4. Do you want a Live-In or Live-Out Caregiver? Live-In Live-Out Live-In OR Live-Out Comments Question Title * 5. How many days a week does your loved one need care? All 7 days Monday - Friday Only The Weekend Other - please explain Question Title * 6. How many hours a day does your loved one need care? Which hours/days? Question Title * 7. In which location (city, state, zip code)? Question Title * 8. Is this a long term position? For sure, one year or longer Less than a year 6 months Less than 6 months Comments Question Title * 9. How is your loved one related to you? Mother Father Other (please specify) Question Title * 10. How old is your loved one Question Title * 11. Does your loved one have dementia? No dementia Slight Moderate (please explain more below) Advanced (please explain more below) Comments Question Title * 12. Can your loved one become aggressive? Not agressive Yes, agressive (please explain below) Comment Question Title * 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 Question Title * 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 Question Title * 15. Do you prefer a male or female caregiver? Or it doesn't matter? Female Male Open to either one Comment Question Title * 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 Question Title * 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 Question Title * 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 Question Title * 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 Question Title * 20. Does your loved one live alone? Lives alone Lives with others (please explain below, who else lives in the house?) Comment Question Title * 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 Question Title * 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 Question Title * 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 Question Title * 24. Will you apply for Medicaid? Yes, applying for Medicaid Not applying for Medicaid Might apply for Medicaid Already has Medicaid Comment Question Title * 25. Is your loved one on hospice or going to be on hospice? Not on hospice Might go on hospice Already on hospice Comment Question Title * 26. Please list your loved one's serious health conditions Question Title * 27. Does your loved one have an easy personality to work with? Yes, easy Not easy - please explain more below Comment Question Title * 28. What are you looking for in a caregiver? Question Title * 29. What kind of caregiver would be a good match or a good fit for your loved one? Question Title * 30. What kind of caregiver would NOT be a good fit for your loved one? Question Title * 31. When do you need your caregiver to start working? Question Title * 32. Do you have plans to issue a W2 or 1099 or any other such form to the caregiver? No Maybe Yes Comment Question Title * 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 Done