Web Submission Referral

Family Care Request

Tell us a little about what you're looking for to help your family. You can fill out as much or as little as you would like, this form simply expedites the initial call with a Care Coordinator if filled out in its entirety.
CONTACT IMMEDIATELY

YES
Entry Method

Web SubmissionManual Entry
Care Recipient's Name

First NameLast Name
Your Name

First NameLast Name
Phone Number
Email
Relationship to Care Recipient
Address Where Care is Needed

Street Address

CityState

Zip Code
Tell us a little about what you're needing for your family
Date

MonthDayYear
Date
What shifts are you looking to cover? (if you have specific days and hours, please list them here)
Please Check Any Existing Conditions / Diagnosis

Balance and Neurological DisordersCVA/StrokeCardiac/Weakness/COPDDementia/Alzheimer'sHospiceOrthopedic/Post-Op CareSpinal Cord Injuries
Duties Needed

AmbulationBed / BathBed MobilityCleaning / HousekeepingCompanion CareDiet RestrictionsDressingFall Risk PreventionFeedingGroomingIncontinence CareMeal Prep/CleanupMedical AppointmentsPositioningRunning ErrandsShowering/BathingTake Notes At Dr AppointmentTake Vital SignsTransfersUsing a gait belt
Special Training Needed

Diabetes ManagementFoley ManagementHoyer TransfersMedication ManagementPost Op OrthopedicSwallowing RestrictionsWound Care Catheter Management
If Transfers Are Needed, At What Level?

Can Stand But Needs Assistance for StabilityNeeds Full Assistance But Can HelpNeeds Full Assistance & Cannot HelpFull Dependent Care Needed
Do you have a preference for a Male or Female Caregiver?

MaleFemaleDoes Not Matter
Will there be any Dogs or Cats in the home?

DogsCatsNone
Does anyone in the home smoke?

YesNo
Hourly Budget Considerations

Do you have a specific budget you need to stay under as far as hourly cost? If so, you can use the following information to help guide you as to your expected Care Costs.

The Hourly Care Cost is calculated by the negotiated rate you make with your caregiver, taxes and BubbieCare Fees. BubbieCare Fees are $5.95 per hour and taxes are approximately 10-11% of the Caregiver's Pay Rate. An example of Hourly Care Cost is seen below:
- Negotiated Caregiver Rate = $20 per hour
- Employer Taxes = $2.19 per hour
- BubbieCare Fees = $5.95 per hour
Your Total Hourly Care Cost for the above scenario would be $28.14 per hour.
Hourly Budget
This can help a Care Coordinator assist you during your call. If you do not have a set budget or are unsure you can leave this field blank.
How did you hear about BubbieCare?
Example - Doctor, Caregiver, Friend, Advertisement, etc
Person's name who Recommended Us?
Status

LEADFIRST HIRE MADEACTIVECANCELLEDDECEASEDSUSPENDEDFAILED LEAD
Should be Empty:

Family Care Request

Hourly Budget Considerations