Care Requirements Input

1
Start Date
Date
Day
Month
Year
2
Suitable Champ/s
3
Who is the Care For?* This field is required.
My Elderly Parents / In-Laws
Myself / My spouse or Partner
My Child / Children
Other
4
Type of Care Required* This field is required.
Frail Care / Elder Care
Dementia Care
Postoperative Care
Disability Care (adults)
Palliative / End-of-Life Care
Companion Care for Elder who are still independent
5
Type of Care Required (Child / Children)* This field is required.
Private Nanny Placements with certified ECD practitioners
Developmental / Behavioral Childcare (ASD; ADHD)
Medical / Health Related Childcare (Post-operative; Disability; Chronic Conditions; Oncology)
6
Please indicate any Conditions / co-morbidities as well as Allergies the care recipient may have. Please also indicate Special Care requirements if any.Of course we will evaluate this still during further engagement but it helps us to already reserve suitable caregivers knowing the potential requirements.
Huge
Large
Normal
Small
Ok
Ok
7
Does the care recipient require medical attention / medical type of care at home?
YESNO
8
Would you like to investigate the possibility of claiming for care through private medical aid?* This field is required.We do work with medical aids directly and certain plans cover home care depending on clients' criteria. (which means we can bill to medical aid directly if the clinical condition allows for an authorisation).
YESNO
9
Name of the Medical Aid & Membership Number
10
Please provide the Medical Aid name & plan. As well as the Membership Number (and dependent code).
11
Please upload a picture(s) / file(s) of your Doctors Letter of Motivation for Home Care (including mention of ICD10 codes).Medical Aid requires this as a prerequisite. If you are on a specifically approved program from your medical aid, please upload the authorisation if available.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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If you don't have the letter of the doctor on hand yet, but you know the ICD10 codes, please input them there.If you are on a specifically approved program from your medical aid, please add the details here.
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Care Provider Requirements so we can matchmake as good as possible.
Please Select
Please Select
Under 35 years old
Over 35 years old
Does not matter
Desired Age of Care Provider
Please Select
Please Select
Female
Male
Does not matter
Gender
Bubbly / talkative
Quiet / subtle in the background
Dominant personality (able to convince and influence in a positive manner and can take charge of situations)
Serving personality (executes as per clear guidance of the care recipient / family)
Style of Engagement
Language Requirement
Other / anything else you'd like to indicate as preference?
14
More Details about Care Recipient & Environment
Please Select
Please Select
No
Yes, outside
Yes, inside
Is the care recipient a smoker?
Please Select
Please Select
Yes
No
Are big Dogs living at home?
Approximate Weight in KG of Care Recipient (for lifting purpose / caregiver strength)
15
Please indicate approximate Caregiving days and times requiredWe can use this information for generating a weekly estimated quote. Remember you can change the bookings at 72 hours notice.
Monday - Friday
Saturday
Sunday
Specific Days Only / Relief Care
12 hour Day Shift
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Row 0, Column 2
Row 0, Column 3
12 hour Night Shift
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Row 1, Column 2
Row 1, Column 3
8 hours/ day
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Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Quick Assistance: 2 hours / day
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Row 3, Column 1
Row 3, Column 2
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24/7 live-in care
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Row 4, Column 2
Row 4, Column 3
12 hour Day Shift
12 hour Night Shift
8 hours/ day
Quick Assistance: 2 hours / day
24/7 live-in care
Monday - Friday
Row 0, Column 0
Saturday
Row 0, Column 1
Sunday
Row 0, Column 2
Specific Days Only / Relief Care
Row 0, Column 3
Monday - Friday
Row 1, Column 0
Saturday
Row 1, Column 1
Sunday
Row 1, Column 2
Specific Days Only / Relief Care
Row 1, Column 3
Monday - Friday
Row 2, Column 0
Saturday
Row 2, Column 1
Sunday
Row 2, Column 2
Specific Days Only / Relief Care
Row 2, Column 3
Monday - Friday
Row 3, Column 0
Saturday
Row 3, Column 1
Sunday
Row 3, Column 2
Specific Days Only / Relief Care
Row 3, Column 3
Monday - Friday
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Saturday
Row 4, Column 1
Sunday
Row 4, Column 2
Specific Days Only / Relief Care
Row 4, Column 3
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Please indicate approximate Companion Care days and times requiredWe can use this information for generating a weekly estimated quote. Remember you can change the bookings at 72 hours notice.
Please indicate approximate hours required. Earliest start date 7am with a min. duration of 3 hours. Live-in is also an option.
Monday - Friday
Row 0, Column 0
Saturday
Row 1, Column 0
Sunday
Row 2, Column 0
Specific Dates only / Relief Care
Row 3, Column 0
Monday - Friday
Saturday
Sunday
Specific Dates only / Relief Care
Please indicate approximate hours required. Earliest start date 7am with a min. duration of 3 hours. Live-in is also an option.
Row 0, Column 0
Please indicate approximate hours required. Earliest start date 7am with a min. duration of 3 hours. Live-in is also an option.
Row 1, Column 0
Please indicate approximate hours required. Earliest start date 7am with a min. duration of 3 hours. Live-in is also an option.
Row 2, Column 0
Please indicate approximate hours required. Earliest start date 7am with a min. duration of 3 hours. Live-in is also an option.
Row 3, Column 0
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Daily Routine of Client & approximate timesWe like to be customer centric and understand our clients' routine to assist as well as possible. If you'd like to share an approximate timetable pls input it here. Click on + to add more line items. Activities could be items such as "meal time; outings; active / passive exercises; games; sleep; grooming routine" etc.
18
When would you preferably like Care Services to START?Please note that we will still send you the "Terms & Quotation" for your approval after receiving this initial care quotation request. Upon successful receipt, we can immediately book the required care for you. We can be as fast as a 24h turnaround time (on business days).
desired START date of care services
Day
Month
Year
19
When would you like Care Services to END (if you have a specific date range in mind)?
desired END date of care services
Day
Month
Year
20
Care Recipient Details (person receiving care)
Name
Phone
Date of Birth (including year)
21
Address where Care is RequiredPlease remember we only provide care in CPT, JHB, Pretoria, PE/Gqeberha, Durban, PMB.
Street Address
Street Address Line 2
City
Region
Postal Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
22
Your Contact Details
Your Name
Your Phone
Your relationship to Care Recipient (if applicable)
Your Email
23
Lastly, may we ask - how did you find out about CareChamp?
Google / online Search
Via Referral / somebody told me about CareChamp
Social Media: facebook, twitter, instagram, linkedin, youtube etc
Other
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