Pre-Screening Eligibility Form
Thank you for your interest in becoming a paid caregiver through Golden Connections Home Care, LLC. Please complete the following form to help us determine your eligibility.
Name of Person Inquiring
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Caregiver Information
(Other than the parent if care recipient is a minor)
Caregiver's Full Name
*
First Name
Last Name
Do you care for a child or adult?
*
Child
Adult
Relationship to Care Recipient?
*
Care Recipient Information
Name of the Person You Are Caring For:
*
First Name
Last Name
Date of Birth of Care Recipient?
*
/
Month
/
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Diagnosis/Disability:
*
Do They Live With Caregiver?
*
Yes
No
Is the child currently in school? If so what are the school hours? (N/A Dor Adults)
*
Insurance Provider? (Aetna, Anthem, Sentara/Centipede, United Healthcare,Humana)
*
Medicaid ID (Required)
*
Additional Information
Does The Caregiver Have Their PCA and/or CNA Certificate? (Not Required)
*
PCA
CNA
Neither
Is The Caregiver Willing To Undergo A Background Check? (Required)
*
Yes
No
Are You (The Parent) Currently Employed
*
Yes
No
Submit
Should be Empty: