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Home
About
About HomeCentris
Vision & Values
Leadership Team
Services
Home Care
Transitional Services
Skilled Home Health
Veterans Program
Primary Care Housecalls
Ancillary Services
News & Media
Home Care Resources
Careers
Join our Team
Existing Team
Contact
Home
About
About HomeCentris
Vision & Values
Leadership Team
Services
Home Care
Transitional Services
Skilled Home Health
Veterans Program
Primary Care Housecalls
Ancillary Services
News & Media
Home Care Resources
Careers
Join our Team
Existing Team
Contact
Form – Caregiver Preferences
Shaun
2019-04-01T17:44:05-04:00
To help us better meet your needs, please update your preferred availability and preferences below.
Caregiver Preferences and Availability
Your Name
*
Please update your availability below: Leave blank if you are not available.
Monday: Available From
12
1
2
3
4
5
6
7
8
9
10
11
:
00
30
AM
PM
Available To
12
1
2
3
4
5
6
7
8
9
10
11
:
00
30
AM
PM
Tuesdays: Available From
12
1
2
3
4
5
6
7
8
9
10
11
:
00
30
AM
PM
Available To
12
1
2
3
4
5
6
7
8
9
10
11
:
00
30
AM
PM
Wednesdays: Available From
12
1
2
3
4
5
6
7
8
9
10
11
:
00
30
AM
PM
Available To
12
1
2
3
4
5
6
7
8
9
10
11
:
00
30
AM
PM
Thursdays: Available From
12
1
2
3
4
5
6
7
8
9
10
11
:
00
30
AM
PM
Available To
12
1
2
3
4
5
6
7
8
9
10
11
:
00
30
AM
PM
Fridays: Available From
12
1
2
3
4
5
6
7
8
9
10
11
:
00
30
AM
PM
Available To
12
1
2
3
4
5
6
7
8
9
10
11
:
00
30
AM
PM
Saturdays: Available From
12
1
2
3
4
5
6
7
8
9
10
11
:
00
30
AM
PM
Available To
12
1
2
3
4
5
6
7
8
9
10
11
:
00
30
AM
PM
Sundays: Available From
12
1
2
3
4
5
6
7
8
9
10
11
:
00
30
AM
PM
Available To
12
1
2
3
4
5
6
7
8
9
10
11
:
00
30
AM
PM
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)
English
Spanish
Russian
Farsi
Arabic
Nepali
Mandarin
Korean
French
German
Hebrew
Nigerian
Turkish
Other
Other
Check if you will NOT work in a home with:
Dog
Cat
Bird
Reptile
Rodent (hamster, gerbil, etc.)
Any animal
If you are human, leave this field blank.
Submit
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