First Time Home Care Agency, * 3957 N.Pontiac Ave, Chicago IL 60634 * Fax 708.357.4627
REQUEST FOR A CAREGIVER / COMPANION / NURSES AID / Home Helper         
                                                                                  Order Number:    #__________   Application Date: ____________(Print)
Family Information
First name ______________________________________________ Last name _____________________________________

Address ______________________________________________City, State, Zip: ____________________________________

Telephone ____________________________________________________Home Fax ________________________________

Email Address__________________________________________________________________________________________

Contact Name  __________________________________________Address ________________________________________

Telephone Number ______________________________________________________________________________________

Number and types of pets. ________________________________________________________________________________

Family needs: __________________________________________________________________________________________

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Duties:
-          Laundry
-          Light Housekeeping
-          General Housekeeping
-          Run Errands
-          Meal Preparation
-          Ironing
-          Bathing and Personal Care
-          Assisting Medication
-          Lifting                  ( lb) ______                 
           Medical Care
           Grocery Shop
           Transportation
           Pet Care
Other __________________________________________________________________________________________________

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POSITION DESCRIPTION

________Live - In   ___________ Live – Out   ________ either

Desired Start Date _____________________Weekly salary range $ ___________ to $ ______________ Gross / Net__________
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Do you employ a cleaning service? _____________________________________________________________________
How often? ______ Daily  _______ weekly ________Biweekly _________ Monthly
Do you require caregiver to have own car? _______________________________________________________________
Age preference: ___________19-30 ____________31-50 ____________51 / older   _________ Open          Male / Female
How long do you plan to employ a potential employee? _____________________________________________________
 
List how many caregivers you have employed and when and for how long?

__________________________________________________________________________________________________

Live-in Caregiver / Companion Accommodations
-          Private Quarters provided. Describe              _________________________________________________________
-          Private bedroom and private bathroom
-          Share Bathroom With? __________________________________________________________________________
-          TV and radio provided in caregiver’s room
-          Telephone
-          Use of family phone, caregiver responsible for own toll or long distance phones
Meals
-Prefer taken with family
-Prefer not taken with family
-Caregiver choice
 
Additional comments to assist with referral:




How did you hear about us?

Agency Terms;
Placement  fee varies and depends on the length of the assignment.
First Time Home Care Agency Charge Placement fee.
1.  Long Term Care: We charge a finders fee equal to one week salary. Fees include a 90 days guarantee to replace any discharged worker, with no additional charge. Fees are paid upon acceptance of the employee. In case a worker is discharged during the first month (full-time permanent job positions only) we will reduce our fee to 25% of the gross wages paid or replace the worker.
2. Temporary placement fee:  the placement fee shall be equal to 15% of the Care Specialist's gross total compensation package for the full term of the employment with client. The minimum placement fee for an Care Specialist employed for 5-10 days shall be $300; the minimum placement fee for an Care Specialist employed for more than 10 days shall be $500.
3.  Other Elder Care Specialists: single day, weekend, and evening whose services will be required for at least 4 hours each day. Client agrees to pay a placement fee equal to $30 for each day the Care Specialist will provide services to Client upon the acceptance of a job offer by an Care Specialist. Any cancellation of services must be made at least 48 hours in advance.

The wages depend on the level of skills/knowledge of worker you need
Depend on your budget you can choose between: Companion, Caregiver, Certified Nurse Aide and Nurse.
Transportation charge of $1 a mile if caregivers uses their own vehicle to transport patient or do shopping. Tolls additional.
(7)Holidays are a 50% surcharge ( New Year, Easter, Memorial Day, 4th of July, Labor Day, Thanksgiving, Christmas Day )

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Your request please send by fax 708 - 357- 4627

                      First Time Home Care Agency  *  3957 N. Pontiac Ave.  *  Chicago IL 60634  *  773 - 625-8365