EagleWings Home Care — Caregiver Intake Form
Welcome to EagleWings Home Care. Please complete this form accurately. Your information will be used to match you with clients that fit your skills, availability, and preferences.
Personal Information
Full Name
*
First Name
Middle Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Home ZIP Code
*
Languages Spoken
*
English
Spanish
French
Amharic
Arabic
Mandarin
Other
Credentials and Experience
Caregiver Type
*
Please Select
CNA
HHA
LPN
RN
Companion/Sitter
Years of Experience
*
Please Select
Less than 1 year
1-2 years
3-5 years
6-10 years
10+ years
Certifications Held
CPR Certified
First Aid
CNA License
LPN License
RN License
Dementia Care Certified
Hospice Certified
None
License Expiration Date
-
Month
-
Day
Year
Date
State that Issued the License
License Number
Availability
Available Days
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Preferred Shift Times
*
Morning 6AM-12PM
Afternoon 12PM-6PM
Evening 6PM-12AM
Overnight 12AM-6AM
Available for Live-in Care?
*
Please Select
Yes
No
Open to it
Maximum Travel Distance
Please Select
5 miles
10 miles
15 miles
25 miles
25+ miles
Skills and Specialties
Clinical Skills
Bathing and grooming
Dressing assistance
Meal preparation
Medication reminders
Mobility and transfers
Range of motion exercises
Wound care
Catheter care
IV management
Blood glucose monitoring
Vital signs monitoring
Client Specialties
Dementia and Alzheimer's care
Parkinson's disease
Post-surgical recovery
Stroke recovery
Diabetes management
Hospice and end of life care
Pediatric care
Developmental disabilities
Mental health support
Cardiac care
Client Preferences
Client Gender Preference
*
Please Select
No preference
Male clients only
Female clients only
Comfortable with pets in the home?
*
Please Select
All Pets - comfortable with dogs, cats and other pets
Dogs Only
Cats Only
No Pets - not comfortable with pets
Comfortable with a smoking household?
*
Please Select
Yes
No
Any other preferences or restrictions?
Emergency Coverage
Available as Emergency Float?
*
Please Select
Yes
No
If called for emergency coverage, how quickly can you respond?
Please Select
Within 30 minutes
Within 1 hour
Within 2 hours
2+ hours
Sign Off
Digital Signature
*
Confirmation
*
I confirm that all information provided is accurate and complete
Communication Consent
*
I understand that EagleWings Home Care may contact me regarding scheduling and care opportunities
Submit Application
Submit Application
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