Personal Support - Intake Form

PERSONAL SUPPORT - INTAKE FORM

FULL NAME (person to be supported)

AGE

GENDER

DIAGNOSIS

DAYS/HOURS OF PSW SERVICE REQUIRED

RATES AGREED

GENDER PREFERENCE

OTHER PREFERENCE

ADDITIONAL NOTES

SPECIFIC REQUIREMENTS

ASSIGNMENT ADDRESS AND PHONE

Billing Information

NAME OF POA/GUARDIAN

RELATIONSHIP TO PERSON SUPPORTED

BILLING ADDRESS

PHONE NUMBER

E-MAIL ADDRESS

Mutual Non-Solicitation

You agree that you will not hire or offer employment to, or otherwise use the services of, directly or indirectly, in a full-time, part-time or temporary capacity, any ASK4CARE personnel unless a mutual agreement is reached.

You also agree NOT to directly or indirectly solicit for hire or employment without the consent of ASK4CARE, any employee with whom you may have had contact during the term of this Agreement.

"The POA / Next of Kin has read and agreed to the details as indicated on this form and hereby agree to discharge payments to settle this account on a periodic basis as per invoice."