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Care for the elderly
(step 1 of 2)
Client information
Name and Surname
*
Phone number
*
Mobile
Email address
*
Relation to patient
Address 1
*
Address 2
Postal code
*
Patient information
Name and Surname
*
Phone number
*
Email address
Date of birth
Date of birth
*
Gender
*
Female
Male
Language (Please specify)
Language (Please specify)
Interests / Hobbies
Brief description of personality traits
Brief description of personality traits
Other
Address
Address 1
*
Address 2
Postal code
*
City/Town
*
Patient requirements
Type of care required
*
Please describe any medical conditions, diseases, disabilities, etc that you require the carer to attend to:
Duration
Duration
Start date
Start date
*
Gross monthly salary
Live in or out
Live in or out
*
Live in
Live out
If live in, please briefly describe the accommodation provided
If live in, please briefly describe the accommodation provided
Do you require your carer to drive?
Do you require your carer to drive?
YES
NO
If yes, do you require them to use their own vehicle?
If yes, do you require them to use their own vehicle?
YES
NO
Brief description of duties
Working hours (Check here if currently undetermined)
unknown
*
unknown
Hours - days of the week (monday)
Monday
Monday to
Tuesday
Tuesday
Tuesday to
Wednesday
Wednesday
Wednesday to
Thursday
Thursday
Thursday to
Friday
Friday
Friday to
Saturday
Saturday
Saturday to
Sunday
Sunday
Sunday to
Household information
Does anyone smoke in the house?
*
YES
NO
Do you have pets?
Do you have pets?
*
YES
NO
If yes, please specify
Do you have any other domestic staff?
Do you have any other domestic staff?
*
YES
NO
If yes, please specify
Candidate preferences
Gender
*
Male
Female
Age range (from / to)
Age from
Age to
Language (Please specify)
Education / Qualification requirements
Other
Contact (Preferred method of contact)
Phone
Phone
E-mail
E-mail
Terms and conditions
Terms and conditions
*
I have read and accept the Handy Helpers terms and conditions
(step 1 of 2)
Click here to read the Handy Helpers terms and conditions
