Client Information Form

New Client Information Form

The purpose of this form is to find caregivers that match your unique needs. All data provided here is confidential under the guidelines set forth by the Illinois Department on Aging.
Full Name *

First Name Middle Name Last Name
Age (approximately) *
Email Address (optional)
Please let us know if you prefer to communicate with us over the phone instead of via email.
Phone Number *
Question 1: Your gender? *

Male Female Other
Question 2: Which zip code do you live in? *
Question 3: Which of the following do you need assistance with? (please check all that apply, your caregiver will provide these services within reason) *

Meal preparation Cleaning Driving & errands Playing games Help with bathing Medication reminders
Question 4: How much time are you looking for from your caregiver? *

Between 4 and 6 hours a day Between 6 and 8 hours a day More than 8 hours a day
Question 5: Which days of the week would you like a caregiver to provide services? (please check all that apply, can be changed later) *

Sunday Money Tuesday Wednesday Thursday Friday Saturday
Question 6: When is the earliest you'd like to see your caregiver? (this helps with scheduling)

No scheduling preference Let's start by 9:30am at the earliest Let's start by 10:30am at the earliest Let's start by 11:30am at the earliest Other (please specify in comment section)
Question 7: When would you like to finish working with your caregiver? (this helps with scheduling)

No scheduling preference Let's finish by 3:00pm at the latest Let's finish by 4:00pm at the latest Let's finish by 5:00pm at the latest Other (please specify in comment section)
Additional Comments: (optional, special requests we should know about)
Should be Empty:

New Client Information Form