Application for Elder Care Services

Please fill out the form below

Client's Name
Client's Representativee (if applicable) Phone
Client's Information:
Home Address: City Zip
Home Phone: Email Address:
Who should we contact?
Client's Limitations:
Hearing   Speech   Vision   Mobility   Swallowing
Breathing   Cognition   Performing Activities of Daily Living
Does the client have any medical conditions?
Special diet and /or nutritional needs:
Allergies:  None  Yes
Referred by (i.e. self, friend, family, etc.):
Please note any special needs:
Other members of household (relatives, domestic help, older siblings etc.)
Name Age Relationship to client
Name Age Relationship to client
Do any members of household smoke?
Pets(please list)
Please tell us about previous care situations, providers, environments (retirement home, elder care companion, relatives):
Full-time      Part-time      Full-time Live-in      24 hour/Overnight
Temporary      As Needed(4 hour minimum)
Start date Days/Hours Salary range (Gross)
Benefits: Paid Vacation weeks after months. Paid sick days    Holidays with pay
Would you be willing to contribute towards health insurance? amount /month.
Will any weekends be requested? Frequency
Will overnights be needed? Frequency Rate of Pay
Describe any travel plans contemplated during the Companion's stay:
With Companion? Without Companion?
Please describe anticipated transportation needs
Will a car be provided? if no, will a car allowance be provided for transportation of client?
Caregiver Characteristics: Please list important qualities you feel the companion should possess.
Caregiver Responsibilities: Please list companion's duties regarding your client.
Housekeeping Duties: Please list the housekeeping duties you will require (no heavy cleaning, shoveling).
Family Information: Please list any information about your family that may help us in making a successful placement.
Please describe what you feel to be the ideal working relationship between your family and your companion.
How were you referred to Babies to Boomers?
Are you currently working with any other agencies to find a companion? If yes, please list

I understand that the full placement fee will be charged to my credit card if I do not pay Babies to Boomers the referral fee before a Babies to Boomers caregiver begins her employment. I have filled out the application as accurately as possible, including reasonably accurate hours, duties, and pay ranges, and understand that the credit and replacement policy will be null and void if the position is not consistent with the above job description. I also agree to submit a contract signed by the caregiver and myself prior to the nanny’s first day of employment.

I have read and understand the terms of this agreement
I Agree
I disagree
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