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Home
About
About HomeCentris
Vision & Values
HomeCentris 360
Leadership Team
Services
Home Care Services
Transitional Services
Skilled Home Health
Veterans Program
Primary Care Housecalls
Ancillary Services
News
Resources
Careers
Join our Team
Existing Team
HomeCentris University
Contact
Search for:
Home
About
About HomeCentris
Vision & Values
HomeCentris 360
Leadership Team
Services
Home Care Services
Transitional Services
Skilled Home Health
Veterans Program
Primary Care Housecalls
Ancillary Services
News
Resources
Careers
Join our Team
Existing Team
HomeCentris University
Contact
Search for:
Form – Caregiver Preferences
Shaun
2021-03-15T09:11:50-04:00
To help us better meet your needs, please update your preferred availability and preferences below.
Caregiver Preferences and Availability
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
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.
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