Form - Caregiver Preferences - HomeCentris Healthcare

Your Name *

In which state do you work?

Maryland

Virginia

Pennsylvania

Please update your availability below: Leave blank if you are not available.

Monday: Available From

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Available To

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Tuesdays: Available From

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Available To

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Wednesdays: Available From

:

Available To

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Thursdays: Available From

:

Available To

:

Fridays: Available From

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Available To

:

Saturdays: Available From

:

Available To

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Sundays: Available From

:

Available To

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Please update your preferences below to us match you with the right client.

Are you working with a family client?

Yes

No

Do you drive AND would you transport a client?

Yes

No

Gender Preference: I will work with:

Male Clients

Female Clients

Both male and female

Do you smoke?

Yes

No

Smoking Preference:

I will NOT work in a house with a smoker

I will work in a house with a smoker

Languages Spoken: (check all that apply)

Check if you will NOT work in a home with: