Elderly Care Client Profile

In home Care Start Date:
Duration of Position
Full Time Amount of hours
Part Time Amount of hours
  Live In Live Out
Client Name (person hiring in-home care)
Home Address
Home Phone
Cell Phone 1
Cell Phone 2


Name of Employer
Phone Number Fax Number
Name of Employer 2
Phone Number Fax Number

Elderly Care Individual

Age Date of Birth
Age Date of Birth

Interests of Elderly Person (park, movies, etc.)

Name Description

Special Information: (please describe if elderly person has special requirements, ie diabetes)

Duties and Responsibilities of the Caregiver:

Driving Light House keeping Grocery Shopping Cooking
Laundry Travel with Family Care of pets Medical Application
Other Explain
Do you have Regular household help? yes no     Frequency:
If you have a pet, please describe:
Do they require care by the person being hired? (ie walks, feeding) yes no
Will Running errands be required? yes no
Will car be provided for caregiver to run errands? yes no
Will caregiver be required to use their personal car to run errands? yes no
Will car be provided for employee's personal use? yes no
If meal preparation is required, describe frequency and what is expected:
Will additional evenings or weekend hours ever be required? yes no
If yes, explain:    
Will employee be left in charge of the household over night? yes no
If yes, explain:    
Briefly describe expected daily routine and main duties of the employee:

Employees Work Schedule: (please fill in required time by the caregiver)
Day of the Week A.M. P.M. Evenings
Are there any other persons living in your home? yes no
If yes, please provide name and relationship
Name Relationship
Will anyone else be present with your caregiver? yes no
If yes, please provide name and relationship
Name Relationship

Qualification of the Caregiver
What are the most important qualifications/characteristics of a caregiver that would be successful relationship with your family?

Description of Home / Neighborhood
Total Rooms Total Bedrooms
Total Bathrooms Swimming Pool
Tennis Court Other children in neighborhood
Are you close to:      
Library Park

Live in Caregiver Information ONLY (answer yes or no below)
Separate bedroom for nanny? yes no
Separate bathroom for nanny? yes no
Separate apartment for the nanny? yes no

Salary Range: Lowest $ to Highest $
Check the following that applies Salary - Net Salary - Gross Hourly
Overtime rate of pay per hour (if applicable) $
Paid Vacation: yes no
Paid Holiday: yes no
Family car to be provided: yes no
Mileage to be compensated if personal car: yes no
Health Benefits: yes no
Travel: yes no
Use of Phone: yes no
Other yes no

Full Time Elderly Placement / Application Fee(s)
Placement Fee $2,250. Due upon Hire Date of Applicant  
Please initial that you understand this fee is non refundable.
We give a 60 day guarantee  
Application Fee $200 (non-refundable). Please use the form below to pay.  
There will be a residual yearly charge for Elderly Care Provider.
Family Care Solutions uses a secure server (SSL) to encrypt your information for security and safety.
Card Holders Name:
Type of card:
Credit Card Number:
Exp Date:
CPU-code on the card:
Billing Address:
Zip Code:

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Family Care Solutions
233 South Main Street, Plymouth, MI 48170
Phone: (734) 459-6930 | Fax: (734) 459-2091
Email: info@family-care-solutions.com