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Personal Care Nevada
Caregiver INTAKE Form
Name
*
First Name
Last Name
Do you already have a client/patient that you are or will be working with as a caregiver through our agency? If so, what is their name?
Have you ever gone by another name? For example, a maiden name or alias?
*
Yes
No
What was your previous name, maiden name, or alias?
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Where are you willing to work?
Las Vegas
Henderson
Pahrump
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Have you lived at this address for 5 years or more?
*
Yes
No
When did you move to your current address?
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Previous Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
How long did you live at your previous adress?
*
How long did you live at your previous address
What year moved in?
*
to
What year moved out?
*
Are you legally eligible for employment in the U.S.?
Yes
No
Are you a US citizen?
*
Yes
No
What is your Social Security number?
*
Do you have a green card or work permit?
*
Yes
No
Place of Birth
*
Race?
*
Please Select
Asian
Black
Native
White
Unknown
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship of Emergency Contact
*
Please Select
Friend
Partner/Spouse
Mother
Father
Brother
Sister
Aunt
Uncle
Niece
Nephew
Other
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Next
Save
Are you able to work the following shifts? Mark all that apply.
Any
Weekdays
Mornings
Saturdays
Evenings
Sundays
Overnight
Other
Do you have a reliable vehicle?
*
Yes
No
Do you have insurance coverage for your vehicle?
*
Yes, Liability only
Yes, Full coverage
None
Have you had any car accidents or citations in the last year?
*
Yes
No
Do you have a current CPR card?
*
Yes
No
Have you had a background check and fingerprinting done within the last six months?
*
Yes
No
Do you speak English well?
*
Yes
Some
Not well
Do you speak any other languages?
Armenian
Italian
Spanish
Russian
Amharic
Other
Are you able to perform the essential functions of the position without accomadations?
Yes
No
Other
Education level?
High School
Some College
Business/Technical
Other
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Next
Save
Job Reference 1
*
Job Reference 2
Signature
Back
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Photo of Your Driver's License, State ID, or Passport (please make sure to take a clear photo)
*
Photo of Your Social Security card (please make sure to take a clear photo)
Save
Continue
Continue
Should be Empty: