Consumer / Advocate
To receive a (FREE) copy of the Weekly Newsletter with current program developments or articles and information about available PCA Candidates, please send an Email to
elitcher@consumerdirectedservices.com
with your name and the phrase
Newsletter Request
.
If you are a Consumer
(an Independent Recipient of Home Care Services - a Person with a Disability, a Senior or a Consumer Advocate) and you are searching for a PCA Candidate, you can distribute an outline of your search criteria (FOR FREE) to the PCA Candidates and the other members of the Consumer Directed Services email database by COMPLETING THE FOLLOWING FORM.
Note: (to move from field to field please use the "TAB" key)
Consumer Information:
Name
Address1
Address2
Address3
Phone ...
Best Time
Fax
E-mail -
Required
Do you authorize Consumer Directed Services to release your E-mail address to the Employment Agencies?
Yes . . . .
No
Consumer's Age:
Younger than 21 . . . .
Between 21 and 30
Between 31 and 50 . . . .
Between 51 and 70
Older than 70
Consumer's Gender:
Female . . . .
Male
Method of Providing the Employee's Salary and Benefits:
Home Care Agency . . . .
Self Pay
Type of Candidates Requested:
Domestic / Homemaking
Personal Care / Home Health
Other Employees - Describe
Candidate's Experience:
Children . . . .
Teens . . . .
Young Adults . . . .
Seniors
Paraplegia . . . .
Quadriplegia . . . .
Hemiplegia . . . .
Amputation
Ventilators . . . .
Wheelchairs . . . .
Lifters . . . .
Other Equipment
Mental Impairments/Alzheimer's Disease . . . .
Visual/Auditory Impairments
Special Diets - Describe
Languages - List
Preferred Candidate Gender:
Female . . . .
Male
Candidate's Documentation:
Social Security Number . . . .
Proof of Identity . . . .
Recommendations
Proposed Schedule:
Daily Hours
. . . . Days Per Week
. . . . Start Time
- Describe
Proposed Salary:
Per Hour
. . or . . Per Day
. . or . . Per Week
Other Selection Criteria / Comments / Recommendations:
FINAL CONFIRMATION:
I am a Person with a Disability, a Senior or a Consumer Advocate searching for a PCA Candidate
Yes . . . .
No
