Details of Person Completing The Form

Full name and title *

Address *

Postcode *

Home telephone number *

Work telephone number *

Email address *

Relationship to person requiring companion or caregiver *

Please supply the name and address of the person responsible for payment of the invoice

Details of Person Who Needs the Companion Caregiver

(If Different To Above, Otherwise Enter N/A)

Persons full name and title *

Persons address *

Persons Postcode *

Persons home telephone number *

Religion *

Nationality *

Age *

Emergency contact 1 name and telephone number *

Emergency contact 2 name and telephone number *

Has the client appointed an attorney from the office of the public guardianship Yes
No

Has the client given someone power of attorney Yes
No

About The Job

Is this position Live In
Live Out
Either

When do you need someone to start

What is the minimum length of the contract

What is the maximum length of the contract

How many days per week Is The Companion Caregiver Required to Work

How many hours each day

What will you pay your companion caregiver per week (NET)

How many weeks paid holiday p.a.

Do you understand that you are liable for her tax and N.I contributions? Yes
No

Will you accept a smoker Yes
No

Can they smoke in the house Yes
No

Do you need a driver Yes
No

If yes for what type of journeys

Will you provide the car Yes
No

Is the car Manual
Automatic

Do you understand that you are responsible for:

Providing a roadworthy vehicle with full tax, MOT and insurance Yes
No

NB If a Motability vehicle, please ensure that Motability have been notified.

Ensuring the companion caregiver has the standard of driving you require Yes
No

May the companion caregiver have use of the car for themselves Yes
No

Do you require the companion caregiver to travel with you Yes
No

If yes then Europe or Worldwide

Do you have any pets Yes
No

Is help required with them Yes
No

Do you employ a cleaner Yes
No

If so how often?

General Duties and Daily Routine

Is cooking required Yes
No

Please describe any special dietary requirements

When should the main meal of the day be provided

At what time (approx) does the client wake and get up

At what time (approx) does the client retire for the night

Is assistance required at night Yes
No

If so how often, and for what

Does the client rest during the day Yes
No

At any particular time(s)

Does the client have regular visitors (both friends and family)

Do they call at regular times / days

Does the District Nurse call Yes
No

If so how often and to do what

Does the client have any hobbies or interests

Does the client have a favourite TV programme

Is Help Required:

With shopping Yes
No

Accompanying to hospital Appointments Yes
No

Escorting to place of worship Yes
No

Any other errands

Personal Details and Duties

Reason for clients need of Companion Care Person

Height of client

Weight of client

Is there any loss of speech, hearing or sight

Is Additional Help Need With:

Getting out of bed Yes

Dressing Yes
No

Feeding Yes
No

Bathing Yes
No

If yes are there any special aids such as a seat across the bath

Is Mobility Restricted?

Can they stand unaided Yes
No

With help Yes
No

With a stick Yes
No

Cannot stand at all Yes
No

Do they walk with a stick Yes
No

Do they walk with a frame Yes
No

Cannot walk at all Yes
No

Are they able to climb steps Yes
No

Unaided Yes
No

With help Yes
No

With a stair lift Yes
No

With extra hand rails Yes
No

Is a wheelchair used inside Yes
No

Is a wheelchair used outside Yes
No

Wheelchair not used at all Yes
No

If a wheelchair is used is it electric Yes
No

Toilet Assistance

Is help required with toileting Yes
No

Getting to the toilet Yes
No

Toilet paper Yes
No

Elimination Yes
No

Bowel or bladder function Yes
No

Is there a commode Yes
No

Is there a degree of incontinence Yes
No

Are aids available (urinary pads, catheter etc) Yes
No

Is there faecal incontinence Yes
No

Do they go to the toilet at night Yes
No

How often

Is help needed Yes
No

Location Of Rooms

Where is the clients Bedroom Upstairs
Ground Floor

Where is the companion carers room Upstairs
Ground Floor

Medication

Does the client take medication Yes
No

How much help is required with medication No help is required
Companion carer to prompt
Companion carer to assist
Companion carer to administer

Confusion

Does the client get confused Yes
No

If so to what extent

Do they wander Yes
No

Please give any further information you feel may be helpful including the general mood of the client

Your Home And Area

Where is your home? Village
City Suburb
City centre

Is your home: Detached
Semi Detached
Bungalow
Terraced
Flat

How many bedrooms?

How many bathrooms?

Does it have a washing machine Yes
No

Does it have a tumble dryer Yes
No

Does it have a garden? Yes
No

Computer / internet facilities? Yes
No

Is it wireless internet Yes
No

If a Live-in position please describe your companion caregivers accommodation

NB All carers must be allocated a separate bedroom.

May the companion caregiver have friends in the home? Yes
No

How Long Would It Take to Reach the Following by Walkng, Bus or Train/Tube?

Local shops

Bus stop

Train / Underground

Main shopping centre

Library

Restaurants

Pub / Bar

Museums

Cafes/Restaurants

Night Clubs

What is your nearest airport and train or tube station

Please describe your family eg "we are a friendly but hectic household.."

Do you require infomation on First Aid Yes
No

How did you hear about Norma Lewis Domestic Staff? *

Have you registered with any other agencies, and if so which ones?

Terms and Conditions Link

NOW THIS FORM IS COMPLETED, PLEASE ENSURE YOU HAVE READ AND UNDERSTOOD THE "FEES" AND THE "TERMS AND CONDITIONS OF BUSINESS" OF NORMA LEWIS DOMESTIC STAFF AGENCY. (YOU SHOULD KEEP ONE COPY OF THESE FOR YOUR OWN RECORDS).

I ALSO UNDERSTAND THAT IT IS MY RESPONSIBILITY TO ENSURE THAT THE CARING COMPANION HAS

A LIST OF MEDICATIONS FOR THE CLIENT
24 HOUR EMERGENCY CONTACT NUMBERS, INCLUDING THOSE OF KEYHOLDERS
INFORMATION REGARDING ANY WISHES THE CLIENT MAY HAVE WITH REGARD TO LIVING WILLS ETC.

SUBMITTING THIS COMPLETED FAMILY REGISTRATION FORM IN ANY FORMAT TO NORMA LEWIS DOMESTIC STAFF AGENCY SHOWS ACCEPTANCE OF THESE TERMS.

Family name *

Date *

GENERAL INFORMATION

Home

BAPAA and What It Means To YOU (For Families and Au Pairs)

What Is An Au Pair? (ECAPS Guidelines)

Important Legal Information For Employers

What Is A Nanny, Mother's Help, Housekeeper And Companion Carer

Testmonials

Families / Jobs Available Now

Applicants Available Now

Useful Contacts And Links

Contact Us

FOR APPLICANTS

How I Can Help Au Pairs

Application Form for Au Pair / Plus

Advice To A New Au Pair

How I Can Help Nannies, Mother's Helps (Live In / Out)

Nannies/Mother's Helps Application Form

Housekeeper's Application Form

Application Form for Companion Caregiver

FOR FAMILIES

How I Can Help Families

Care For the Elderly Person

Family Registration Form for an Au Pair

Family Registration Form For A Nanny, Mother's Help (Live In / Out)

Family Registration Form For A Housekeeper

Family Reg Form For Companion Caregiver

Terms

Fees

Family Registration Form for a Companion Caregiver