Personal Support – Intake Form

FULL NAME (person to be supported)*

AGE*

GENDER

DATE OF BIRTH*

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.

Agree "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."