Nü Momish Help at Home Intake
Share a few details and choose the support you need—then schedule your 10-minute Welcome Call.
Client Information
First Name
*
Last Name
*
Email Address
*
example@example.com
Mobile Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Preferred Contact Method
*
Phone
Text Message
Email
What kind of help are you looking for?
*
Mama Needs a Hand: practical in-home support
Babysitting: trusted in-home childcare
Mama Needs a Hand
Mama Needs a Hand is practical home support, not a professional cleaning service. Our Mom Assistants help tackle everyday household tasks while supporting you and your family. Visits are 2 hours and $75 flat. Nü Momish Members receive 10% off eligible Help at Home services.
What would you like your Mom Assistant to help with?
*
Laundry folding
Dishes
Light tidying
Organizing
Childcare support while I’m home
General home reset
Other
Tell us more about what you're hoping to accomplish during your visit.
*
How many children live in your home?
*
What are their ages?
*
Will children be present during the service?
*
Yes
No
Do you have pets in the home?
*
Yes
No
Please describe the pets, along with any home details, family needs, accessibility needs, allergies, or service expectations that would be helpful for us to know.
*
Babysitting
Babysitting starts at $25/hour with a 3-hour minimum for one child. Families with 2 or more children receive custom pricing based on their childcare needs. Nü Momish Members receive 10% off eligible Help at Home services.
How many children will need care?
*
Please Select
1
2
3
4+
Child 1 name
*
First Name
Middle Name
Last Name
Child 1 age
*
Child 1 date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Child 2 name
First Name
Middle Name
Last Name
Child 2 age
Child 2 date of birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Child 1 allergies, medical considerations, disabilities, developmental needs, or additional support needs the babysitter should be aware of
*
If yes, please explain the support needs or care considerations
What does your child enjoy?
Which responsibilities might the babysitter need to help with?
*
Playtime
Bottles/Feedings
Snacks
Meals
Diaper Changes
Potty Assistance
Nap Time
Bedtime
Homework
Other
Do you have pets?
*
No
Yes
If yes, please describe your pets
Final Follow-Up and Scheduling
Have you used a Nü Momish service before?
*
Yes
No
Are you currently a Nü Momish Member?
*
Yes
No
Not yet, but I'd like to learn more
Book your 10 min discovery call on the next page!
This gives us an opportunity to learn more about you an assign you a sitter or mom assistant that best fits your family needs.
SUBMIT + SCHEDULE MY CALL
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