Cell phone: Email address: □ □ □ * do you prefer to be contacted at? Home Work Cell phone □ □ □ * Which do you prefer to by contacted by? Mail Phone Email method Consumer/Employer language: Which language do you speak, read and write? Primary language: _____________________ Secondary language: __________________________ Individual Provider Services: □ I prefer my worker is a : Female Male No Gender Preference I am looking for an individual provider who is able to provide: (check one only) (If your circumstances change and you need a different type of service, call your registry coordinator) Routine Care (hire a worker for a regularly scheduled basis) Emergency/Back-up (hire someone to fill in when your routine worker doesn’t come) Relief (hire someone on a pre-arranged basis to relieve the routine worker □ □ I am looking for a live-in provider. Yes No □ □ I need a provider who has completed DSHS Delegation training. Yes No Living Conditions: □ □ Do you smoke? Yes No □ □ Do you mind if the worker smokes? Yes No □ □ Do you need a special diet? Yes No □ □ Are you sensitive to perfumes and fragrances? Yes No Allergies:_____________________ Do you have: Dogs Yes No Cats Yes No Birds Yes No □ □ □ □ □ □ Other Pets/Animals: __________________________________________________________ Personal Care Do you need assistance with: Yes Dressing and Undressing? Toileting? Bladder and Bowel Care?
Cell phone: Email address: * phone do you prefer to be contacted at? □ Home □ Work □ Cell * Which method do you prefer to by contacted by? □ Mail □ Phone □ Email Consumer/Employer language: Which language do you speak, read and write? Primary language: _____________________ Secondary language: __________________________ Individual Provider Services: I prefer my worker is a : Female Male No Gender Preference □ I am looking for an individual provider who is able to provide: (check one only) (If your circumstances change and you need a different type of service, call your registry coordinator) Routine Care (hire a worker for a regularly scheduled basis) Emergency/Back-up (hire someone to fill in when your routine worker doesn’t come) Relief (hire someone on a pre-arranged basis to relieve the routine worker I am looking for a live-in provider. □ Yes □ No I need a provider who has completed DSHS Delegation training. □ Yes □ No Living Conditions: Do you smoke? □ Yes □ No Do you mind if the worker smokes? □ Yes □ No Do you need a special diet? □ Yes □ No Are you sensitive to perfumes and fragrances? □ Yes □ No Allergies:_____________________ Do you have: Dogs □ Yes □ No Cats □ Yes □ No Birds □ Yes □ No Other Pets/Animals: __________________________________________________________ Personal Care Do you need assistance with: Yes Dressing and Undressing? Toileting? Bladder and Bowel Care?
ConsApp_rev2016.docx