Would love some Caring Supports? Complete the brief below and we will be in contact with you shortly! ADVOCATE/SUPPORT PERSON DETAILS * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Email * PARTICIPANT PERSONAL DETAILS * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Email Date of Birth * MM DD YYYY Cultural background * Preferred language * Gender/Pronouns * DISABILITY AND OR/MEDICAL CONDITION – DIAGNOSIS & DESCRIPTION * Please click on ANY relevant conditions from the list below: Client displaying challenging behaviours Client with Mental health issues Client with Physical disabilities Client with Intellectual disabilities Client with Autism Spectrum Disorder Client with Epilepsy Client with Down Syndrome Client with Vision Impairments Client with addiction Client with Mobility Issues Client with Down Syndrome Other SHIFT PREFERENCES: * Please click on the type of Shifts you require: Personal Care Community Access Domestic Assistance House Cleaning Night Shift Respite Care Sleepover (Passive or Active) Transport/Escort AVAILABILITY * How many care hours in total per week is required? 0-20 20-40 40 + Please select preferred days and shift times Monday: Morning Day Afternoon Evening Overnight Tuesday Morning Day Afternoon Evening Overnight Wednesday Morning Day Afternoon Evening Overnight Thursday Morning Day Afternoon Evening Overnight Friday Morning Day Afternoon Evening Overnight Saturday Morning Day Afternoon Evening Overnight Sunday Morning Day Afternoon Evening Overnight Thank you!
