Employee Intake — Preferences
Service preferences, availability, and working conditions — update any time.
Employee name (First, Last)
Date
Homemaking
Respite care
Adult companion
Night supervision
Individual community living support (ICLS)
Individualized home supports (IHS)
IHS with training
IHS with family training
PCA / CFSS personal care
How did you hear about us?
Availability (days / hours)
Cities / neighborhoods you prefer to work in
Elderly
Adults
Children
Male clients
Female clients
Smoking in home
Cats
Dogs
Exotic pets
Car
Bus
Taxi / rideshare
None
Yes
No
If yes, list allergies
Any weight / lifting restrictions?
Yes
No
What kinds of care activities did you perform?
Yes
No
Yes
No
Yes
No
Employee signature
Clear
Date
Submit
