Contact a Matching Expert

Point of Contact Name

Primary Contact Phone Number

Care Recipient Information

Care Recipient Name

Policy/ Claim ID

Address

City

State

Zip Code

What is the care recipient's age?

Care recipient average height and weight?

Example: 5" 5' 150lbs

How long will the care recipient be needing services?

More than 3 monthsLess than 3 monthsOne Time

When is the preferred start date?

Please note, if The Helper Bees is vetting new caregivers, it can take 2 weeks to start care.

Preferred Schedule

Day

Shift Length

Start Time

Please tell us a little more about the Care Recipient

What are the care recipient's interests and/or hobbies (past or present)?

How would you describe the care recipient's personality?

Example: easy going, stubborn, quiet, outgoing, funny, forgetful

What do you and the care recipient value in a caregiver?

Example: self-starter, quiet, non-smoker, mature, gender, reliable

Are you and the care recipient most comfortable with a female or a male caregiver?

FemaleMaleNo Preference

Are there any pets inside or outside of the home?

YesNo

Is there any smoking inside or outside the home?

NoneInsideOutside Only

If there is anything else you think we should know, please add it in the space below:

Examples Include: Unknown Discharge Date, Exact Dates for Temporary service, Assistance to feed pets

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Fall Supervision	Cognitive Supervision	Meal Preparation
Eating	Bathing & Showering	Grooming & Dressing
Incontinence Care	Toileting Assistance	Ambulation (incl walking)
Transferring Assistance	Medication Administration	Medication Reminders
Companionship	Laundry	Light Housekeeping
Heavy Housekeeping (ex. mopping)	Doctor Appointments	Errand Running
Grocery Shopping	Salon visits	Trips around town
Other