female who is (are) my*
He/She is * years old and requires* non-medical care.
The care is needed within weeks in* ,
A non-smoking caregiver Yes Not important
Caregiver with valid driver license is required Yes Not important
Caregiver with car is required Yes Not important
Certified caregiver is reqired (CNA, HHA, etc.) Yes Not important
Information of the contact person (not the care recipent)
First Name* Last Name*
Adress* (yours)
City* State     Zip*  
E-mail*
Day Phone* - -
Evening Phone - -


For best match please answer the questions bellow.

Please specify care giving schedule

 

Morning

Daytime

Evening

Overnight

Select All

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday


Please select all activities that caregiver should participate. (check all that apply)

Activities of Daily Living (ADLs):

Ambulation
Bathing
Bed In/Out
Bowel/Bladder
Dressing
Feeding
Grooming
Night Assistance
Oral Hygiene
Prosthesis Care
Range of Motion
Respiration
Skin Care

Instrumental Activities of Daily Living (IADLs)

Companionship
Feeding Pets
Heavy Cleaning
Laundry
Light Cleaning
Meal Cleanup
Meal Planning
Meal Preparation
Other IADLs
Reading
Shopping
Transportation
Yard Work

Social activities preferred

Arts and crafts
Cards and games
Interaction with others
Movies
Outdoor activities
Pet therapy
Prayer groups
Reading
Social events
Television
Visiting activity centers
Other

Medical conditions of care recipient  (check all that apply)
Alzheimer's/Dementia
AIDS
Diabetes
Quadriplegia/Paraplegia
 Heart Disease
Respiratory Problems
Arthritis
Cancer
 Parkinson's Disease
Other:
 
In addition to English the caregiver should speak:

Would you consider a caregiver who is not a native English speaker? Yes No

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