Pre-Screening Eligibility Form

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.
Caregiver Information
Caregiver's Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Do you care for a child or adult?*

ChildAdult
Care Recipient Information
Name of the Person You Are Caring For:*

First NameLast Name
Relationship to You?*
Date of Birth of Care Recipient?*
Social Security Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Diagnosis/Disability:*
Do They Live With You?*

YesNo
How Many Hours Per Week Do You Care For Them?*
Insurance Provider? (Aetna, Anthem, Sentara/Centipede, United Healthcare,Humana)*
Medicaid ID (If unknown type "will obtain")*
Additional Information
Are You CPR and First Aid certified? (Not Required)*

YesNo
Do You Have Your PCA and/or CNA Certificate? (Not Required)*

PCACNANeither
Are You Willing To Undergo An Background Check? (Required)*

YesNo
Are You Currently Employed*

YesNo
Should be Empty:

Caregiver Information