Theresa's Place #1 Homecare
Caregiver Application
First Name
Last Name
Phone
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Email
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What is your availability?
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Full Time
Part Time
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Where are you located?
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What hours are you looking for?
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Do you have reliable transportation?
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Yes
No
Option 3
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Are you willing to travel with in and around the area?
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Yes
No
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Do you have experience as a care giver?
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Yes
No
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If you have experience, how many years of experience do you have? ( If non put N/A)
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Are you comfortable working with clients that may have specific conditions like dementia, Alzheimer’s, or physical disabilities?
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Yes
No
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Are you CPR and First Aid certified?
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Yes
No
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Do you have a CNA (Certified Nursing Assistant) license or any other caregiving certifications?
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Yes
No
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If you have certifications please list them below.
Can you provide references from previous employers or clients?
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Yes
No
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Please provide your references below.
Are you available for overnight or weekend shifts?
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Yes
No
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Are you comfortable with personal care tasks such as bathing, dressing, and toileting?
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Yes
No
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Do you prefer working with male or female clients, or does it not matter to you?
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Male
Female
Does Not Matter
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Why did you choose to become a caregiver?
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What would you say are your strengths as a caregiver?
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How do you handle stressful situations or emergencies?
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Are you comfortable with pets in the home?
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Yes
No
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How would you describe your communication style?
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Do you have a valid driver’s license and car insurance (if driving clients is required)?
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Yes
No
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Are you authorized to work in the United States?
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Yes
No
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Are you willing to undergo a background check and drug screening?
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Yes
No
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Are you vaccinated against [specific requirements, e.g., COVID-19, flu]
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Yes
No
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What is your hourly pay expectation?
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