Personal Assistant Enrollment Form
To add your information to the list of available Personal Assistants, please complete and submit this form. As soon as your information is received it will be kept on the list for 10 days and forwarded to Consumers when requested.
Consumer Directed Services has no direct role in the employment process and can make no guarantee regarding your employment search.
Consumers and/or their Surrogates are exclusively and directly responsible for all decisions regarding the hiring, training and supervision of their Personal Assistant. If a Consumer wishes to consider your application, they will contact you directly and provide you with all the information you will need regarding the terms and conditions of your employment relationship.
Note - Please do not include any confidential information (Social Security Number) on this page.
After you submit this information, please print a copy of the Confirmation Page for your records.
Thank you for choosing to use Consumer Directed Services.
Best Regards
Edward Litcher
Reminder: to move from field to field please use the "TAB" key.
To promote an optimal level of service, please answer each of the following questions.
Personal Assistant Information:
Name
Address1
Address2
Address3
Phone
Fax
E-mail -
Required
Experience:
Domestic / Homemaking . . . .
Persona Care / Home Health
Children . . . .
Teens . . . .
Young Adults . . . .
Seniors
Paraplegia . . . .
Quadriplegia . . . .
Hemiplegia . . . .
Amputation
Ventilators . . . .
Wheelchairs . . . .
Lifters . . . .
Other Equipment . . . .
Mental Impairments/Alzheimer's Disease . . . .
Visual/Auditory Impairments . . . .
Other Experience - Describe
Special Diets - Describe
Languages - List
Documentation:
Social Security Number . . . .
Proof of Identity . . . .
Recommendations
Requested Schedule:
Daily Hours
. . . . Days Per Week
. . . . Start Time
Other Selection Criteria / Comments / Recommendations:
