Form - Caregiver Preferences - HomeCentris Healthcare

Your Name *

In which state do you work?

Maryland

Virginia

Pennsylvania

Monday: Available From

Available To

Tuesdays: Available From

Available To

Wednesdays: Available From

Available To

Thursdays: Available From

Available To

Fridays: Available From

Available To

Saturdays: Available From

Available To

Sundays: Available From

Available To

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: