Host: Key Information
Our Contact Person Relationship to host
Host Details Age
Date of birth
When would you like your carer to start?
Do you need your carer to drive? If yes, do you have a car they can drive? Would you be happy for your carer to smoke outside the house? If yes, please specify
Would you prefer your companion to be:
Please mark if you would NOT be happy for your companion to be:
What type of location do you live in? What time do you usually get up?
What time do you usually go to bed?
Do you need your carer to be available to you during the night? If yes, how often and for how long each time? (Please note a regular night-carer cannot be expected to work full days.)
If you wake during the nights but do not need your carer to be available, are your movements likely to disturb them? If yes, please give details:
For part-time companions are there any times/days you specifically need your companion to be available to work?
Expected salary range?
How did you hear about Home Care Companions?
Host: Your Needs Assessment What is your current state of health?
Do you have any mobility or physical restrictions? If yes, please specify:
Do you have any history or currently suffer from any mental health conditions including depression and dementia? Do you have any special dietary requirements? If yes, please specify:
Do you have any allergies? If yes, please specify:
Who is available to help you if necessary when your carer is not working / available?
Please specify their proximity and general availability:
Host: Your Task Profile Your expectations of duties. Please indicate duties below that may apply to your position:
Are there any other specific duties you expect from your carer?
Host: Now, About You Nationality
Country of birth
How would you describe your personality?
What did you do before you retired?
What were / are your interests and hobbies?
What type of music do you like?
Do you enjoy being on your own: What types of personalities would you get on with?
What type of personality would you not get on with?
Are there any other qualities, qualifications or experience you expect from your carer?
All of our carers are already in the UK. Some are not British nationals. What is the minimum level of English you would find acceptable? Do you have any other nationality/language requirements? If yes, please specify:
Would you consider interviewing a companion who had a pet dog or cat she/he wanted to bring with her/him? If you had a companion or carer before, can you tell us anything good or bad about that experience that may influence your feelings about having a live-in carer/companion?
Host: Your Home Environment What type of home do you live in? Do you have a dishwasher? How far are the local shops? (approximately)
How far are the main high street shops? (approximately)
How far is your nearest town? (approximately)
What is your nearest train/tube station and how far is it from your home? (approximately)
How far is the closest bus stop from your home? (approximately)
What other domestic help do you have in the home and what is their frequency? (Cleaner, gardener, other carers?)
Can you add any more detail to the description of your home and what it is like inside?
How would you describe the street you live in? Please indicate if you will provide your carer with:
If other, please specify
Can you further describe your carer’s accommodation / bedroom?
Does anyone else live in the house? If yes, please specify:
How often would you say you have visitors?
Please provide any more information that you can about you/your home / your family / how far away your family members live?
I hereby confirm that the above information is true to the best of my knowledge and I have read and understood the terms and conditions Today's Date
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