application for working caregivers help

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Application for working caregivers help

APPLICATION
We want to help you by freeing some time for you in your life. (If you reached this page looking for our info on a caregiver job click this).

To search for a caregiver job or a caregiver click this.)

The purpose of this application is to help you with us to see how effective we can be in helping your loved one.
The information will be kept confidential.

If you have any questions feel free to call now
1-877-443-8636
(1-USS-4-GET-ME-NOT). This form is free to fill in. The agreement is needed to begin services. We do look forward to having an opening at your desired time. We will contact you if we have any questions.
There are some required (*) information boxes. Completeness determines prompt service. To help your parent maintain senior independent living and to keep them alive as well as out of the hospital and nursing home please do not delay your application. If you would like to get a more visual look at the application information you may download PDF application file here.

Our main focus is on preventing unnecessary deaths, and nursing home and hospital admissions by assuring prescription drugs being taken as prescribed. We can talk about medications. We are willing to help in related areas over the phone or through the mail. In the event of a medical emergency we will perform your wishes. Depending on the health status and physical abilities we can assist to a certain extent.

If we needed to contact Emergency Medical Services (EMS) their local contact number is needed because "911" is not the same in all areas of the country. We need to have the local EMS number(usually the loved ones' local Police Department including the area code). If there are any allergies to drugs and EMS needs to know we can inform them on your behalf. If they have a medic alert id we can tell EMS what type to look for. We call it your definition of an emergency
Which is similar to
AUDIO ANNOUNCEMENT
This picture will link to another site to help when you may not be able to speak or prefer another method for help-

If you want to keep the information private it is okay.
Just like the question about an advanced medical directive or (POAHCD)

Power of Attorney Health Care Directive

or living will again in the case of an emergency, as well as the primary physician to be contacted.

The application requests for information about nearby contacts just in case it is not an emergency (as you define it or we perceive it) to contact a nearby neighbor can be very helpful especially one who is entrusted with a key.
The special services are designed for us to make contact for you during business hours if we are permitted to.
It depends on the individual circumstance if a power of attorney is needed.
Again that is why we ask so many questions just to help you and your loved one. We have found a few websites that we would recommend for you to look at for further help and guidance.
This site is sponsored by Personal Voice Inc.

To summarize the areas of benefits and opportunities.
1, To establish a relationship with your loved one.
2, To assure both you and your loved one of your care and concern,
3, Establishing a routine to be expected on morning, noontime and evening.

YOUR CONTACT INFORMATION

Please note that all fields followed by an asterisk must be filled in.

First Name*
First Name*

Last Name

Home Phone

Business Phone

Street Address

City

State/Prov

Zip/Postal Code

Country

E-mail Address*
E-mail Address*

Fax

Cell Phone

Loved One's Name, First*
Loved One's Name, First*

Midlle Initial

Last Name

Home Phone*
Home Phone*

Cell Phone

Work Phone

Street address

City

State/Province

ZIP

Country

Your relationship
to loved one

(Include your name for loved one
If you believe it can be helpful- their name for you)

Service Details
Exactly what you want us to do
(Please detail and please give dates and time for all outside activities).
UNLESS OTHERWISE REQUESTED, ALL DAILY CALLS TO LOVED ONE’S HOME
ARE MORNING, NOON-TIME AND EVENING.

Wake up call (If so when)

Check up call

Medications

Check Blood Sugar

Check Blood Pressure

Diet

Meals on Wheels

Vitamins, Fiber, Herb Supplements

Exercise, Walk, Dance, Tai Chi, Yoga. Martial Arts

Salon/ Hair care

Doctor Appointments,
Prescription Refills

Schedule confirmation
Nurse
Homemaker

Elder Care
Transportation

CHORES

Entertainment
Activities

IF NOT IN EASTERN STANDARD TIME ZONE THEN PLEASE GIVE THEIR RELEVANT TIME ZONE*
IF NOT IN EASTERN STANDARD TIME ZONE THEN PLEASE GIVE THEIR RELEVANT TIME ZONE*

Health Status/Medical Condition, if yes please give details below*
Health Status/Medical Condition, if yes please give details below*

Allergies to Drugs?

Medic-Alert ID Card?

Advanced Medical Directive
or Living Will?

Primary Physician’s Name

Phone

Address

If there is no answer on the phone, what warrants a health crisis (Emergency) in your estimation?*
If there is no answer on the phone, what warrants a health crisis (Emergency) in your estimation?*

Do they go out often?

Is it okay for them to not take any of their medication?*
Is it okay for them to not take any of their medication?*

If needed what emergency contacts do you wish us to make?
Their Local Emergency Contacts
*For EMS ("911")-need the loved one’s local emergency service number.
Do any of below have key access?
*(911) often varies according to counties and municipalities. *
If needed what emergency contacts do you wish us to make?
Their Local Emergency Contacts
*For EMS ("911")-need the loved one’s local emergency service number.
Do any of below have key access?
*(911) often varies according to counties and municipalities. *

First Contact Name *
First Contact Name *

First Contact Phone Number(s)*
First Contact Phone Number(s)*

Key access?

	Yes
	No

Second Contact Name*
Second Contact Name*

Second Contact Phone Number(s)*
Second Contact Phone Number(s)*

Key access?

	Yes
	No

Third Contact Name

Third Contact Phone Number(s)

Key access?

	Yes
	No

Special Services

	A Assistance with writing or form completion, compiling information
	B Bill sorting coordination of bills to benefits
	C Consulting with Medical Staff on a limited basis
	D Medical Billing Problem Resolution
	E Negotiating with insurance companies for eligible benefits

Special Services:Please give additional information. Commonly a limited power of attorney for the specific circumstance is required.

Do you have any power of attorney?

Optional Services,
Presidential greetings arranged
Gift Suggestions,
Book and Film Finding (Purchasing at additional cost)
Special discussions of Old Time Radio, early Films, early Television

Birthday/Anniversary reminders

Signature
By submitting this application, I affirm that the facts set forth in it are true and complete.
I understand that if I am accepted as a client, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate cancellation.
This application will be considered part of the agreement, which client and loved one should sign.
There is no independent investigation; actions are entirely based on loved one’s verbal answers.
At this time only loved ones whose primary language is English can be accommodated
For protection and assurances all calls between client, loved one and third parties are to be recorded.

Client ‘s Name *
Client ‘s Name *

Typing name verifies signature*
Typing name verifies signature*

Date*
Date*

Love One’s Name *
Love One’s Name *

Signature

Date

Why are there so many questions?
Whether there is a need for a wakeup call,
check blood pressure or blood sugar,
ensure medications, appointments, diets,
meals on wheels, visiting nurse, homemaker, elder daycare,
vitamins, fiber or herb supplements,
exercises in various forms,
dance, Tai Chi, Yoga Martial arts, weight bearing, walking,
elder care, transportation, Senior center activities,
shopping, entertainment.
We want to be the most comprehensive service for your loved one. To continue the process go to
The agreement
or look below

Agreement by Personal Voice Inc. Your Forget-me-not Service in the Computer age

Please note that all fields followed by an asterisk must be filled in.

This is an Agreement made between PERSONAL VOICE, INC. a New Jersey corporation having an address at 4032 Route 516, Matawan, NJ 07747 (“PVI”) and (the “Client”)

First Name*
First Name*

Last Name*
Last Name*

Street Address*
Street Address*

City*
City*

State/Prov*
State/Prov*

Zip/Postal Code*
Zip/Postal Code*

Country*
Country*

Background:
A.
Attached hereto is a copy of an Application filled out by the Client with respect to PVI Services desired by Client to be rendered to the Client’s “Loved One”.
B.
The information, terms and conditions of the Application are hereby made part of this Agreement; and terms in quotation marks in this Agreement but not defined herein but rather are defined in the Application
C.
PVI hereby accepts the Application, based upon the truthfulness and completeness of the information supplied in the Application.
NOW, THEREFORE, it is agreed as follows:

1.
Term of this Agreement

1.1
The “Term’ of this Agreement

shall commence on **
shall commence on **

and shall continue for**
and shall continue for**

days, after which either party, without cause, may terminate this Agreement on three (3) days’ written notice.
1.3
This Agreement may be terminated by PVI at any time for “Good Cause”, which shall include (a) material misrepresentations or omissions in the Application; (b) lack of cooperation (voluntarily or involuntarily) of the Loved One or of the Client and (c) failure to pay PVI for its services within three (3) business days after the due date of the payment.
1.4
In case of termination by Client for Good Cause, the Client shall be entitled to a pro-rata refund of any prepayment on a per diem basis. In case of termination by PVI for Good Cause, Client shall not be entitled to any refund

2
Obligations of Client to Update Information in the Application
Client agrees immediately to advise PVI of any material change of the information concerning the Loved One contained in the Application and of any change in the contact information for Client.
3
PVI SERVICES
3.1
The weekly services to be provided by PVI during the Term are as follows [check one]

	Silver Package Fifteen(15) one-minute calls/week $22.00 per week plus $1.00 per excess minutes
	Gold Package Fifteen(15) three minute calls/week $50.00 per week plus $1.00 per excess minutes
	Platinum Package Fifteen (15) five minute calls/week chatting or waiting up to five minutes for confirmation $85.00 per week plus $1.00 per excess minutes

Customized calls

There also are Special Services at an additional rate Billed in Fifteen Minutes Increments of $60/hr discounted to $40/hr only with gold and platinum packages.(check desired and send or paste specific information)

	A Medical Billing Problem Resolution
	B Bill sorting coordination of bills to benefits
	C Negotiating with insurance companies for eligible benefits
	D Consulting with Medical Staff on a limited basis
	E Assistance with writing or form completion, compiling information

Special Services Specifics

optional fun services$60/hr flat rate also billed in fifteen minute blocks.

	1-Presidential greetings arranged
	2-Gift Suggestions, Book and Film Finding (Purchasing at additional cost)
	3-Special chats of Old Time Radio, early Films, early Television

Specify Fun Services

3.2
The specific reminders or other communications to be made with the Loved One are set forth in the Application
4
Payment to PVI
4.1
Contemporaneously with the execution of this Agreement by PVI and the Client, the Client agrees to pay and is paying to PVI the “Set-up Fee”.Set-up Fee waived when submitted via this page.
4.2
While PVI’s Services will be performed on a weekly basis, the ”Service Fee” must be paid one month in advance, on the* *

3.2
The specific reminders or other communications to be made with the Loved One are set forth in the Application
4
Payment to PVI
4.1
Contemporaneously with the execution of this Agreement by PVI and the Client, the Client agrees to pay and is paying to PVI the “Set-up Fee”.Set-up Fee waived when submitted via this page.
4.2
While PVI’s Services will be performed on a weekly basis, the ”Service Fee” must be paid one month in advance, on the* *

day of each month, commencing on**
day of each month, commencing on**

5
Limitations of Liability
CLIENT HEREBY AGREES THAT PVI, ITS DIRECTORS, OFFICERS, EMPLOYEES AND INDEPENDENT CONTRACTORS HIRED BY PVI TO PERFORM PVI SERVICES SHALL NOT BE LIABLE FOR FAILURE PROPERLY TO PERFORM PVI SERVICES, EXCEPT FOR GROSS NEGLIGENCE OR WILLFUL MISCONDUCT.

6
Non-binding Mediation before Litigation
6.1
Agreement to Mediate
a
All claims or disputes arising out of or in any way relating to this Agreement or any of the parties' respective rights and obligations arising out of this Agreement, the parties agree that before proceeding to litigation they will first submit the claim or dispute to non-binding mediation by a single mediator in Monmouth County, New Jersey, under the auspices of (1) the American Arbitration Association (the "AAA"), in accordance with the AAA's "Commercial Mediation Rules" then in effect, or (2) under the auspices of JAMS or any other mediation service agreed upon by the parties

b
A party to this Agreement having a claim or dispute subject to paragraph 6.1 may not institute any legal action against any other party to this Agreement unless the mediation proceedings have been terminated as a result of a written declaration of the mediator that further mediation efforts are not worthwhile
6.2
Expenses of Mediation
The fees of the AAA or other mediation service and the mediator shall be borne one-half by the Company and one-half by Client.

6.3
Enforceability
A party's right to mediation may be specifically enforced by said party.
6.4
Certain Limitations
All statements, promises, offers, views and opinions made or communicated by any party in the mediation proceeding will be secret and confidential in all respects, and will not be discoverable or admissible for any purposes, including impeachment, in any litigation or other proceeding between the parties. However, evidence otherwise discoverable or admissible will not be excluded from discovery or admission as a result of its use in the mediation proceeding.

7
Entire Agreement; Modification
7.1
This Agreement, together with the Application, constitutes the entire and only agreement between the parties and supersedes any and all prior or contemporaneous agreements, representations, and understandings with respect to PVI ServicesThis Agreement may be modified only by a writing signed by PVI and Client.

PERSONAL VOICE, INC. by Joseph or Victoria Quinn

Client by typing name verifies signature**
Client by typing name verifies signature**

Over 18 years of age*
Over 18 years of age*

	Yes
	No

YOU MAY PAY BY CREDIT CARD
with any button below.
You will be taken to a secure PayPal page.

Prepay monthly service=10% discount
SILVER SERVICE $88.00=only $79.20
1 Minute call length
15 calls/week -

Prepay monthly service=10% discount
GOLD SERVICE $200.00=only $180.00
3 Minute call length,
15 calls/week
-

Prepay monthly service=10% discount
PLATINIUM SERVICE $340.00=only $306.00
5 minute call length
15 calls/week
-

This Button is for a $60 Service
Deposit if you want the $60/hour
Fun Services.
or Special Services
Billed in 15 minute increments.

Fast Feedback To Us
or Call 1-877-443-8636-1-USS-4-GET-ME-NOT

Please note that all fields followed by an asterisk must be filled in.

Only Form Out If you want us to reply. Thanks

First Name*
First Name*

Last Name

E-mail Address*
E-mail Address*

City

State/Prov

Zip/Postal Code

Country

Did you find what you are looking for?

	Yes
	No

What are you looking for

Are you a caregiver

	Working with a senior
	Seeking employment as a caregiver
	Working as a paid caregiver
	Needing additional income at home
	See our free webpage offer
	See our caregiver job description

Websites for general information on caregiving

	YES
	NO

Our best choices for websites on caregiving

	yes
	no

Legal issues about caregiving

	yes
	no

Financial issues about caregiving

	yes
	no

Spiritual concerns in caregiving

	yes
	no

Chat boards for caregivers

	yes
	no

Fast Feedback Form anything else?

Disclaimer
With the above adjacent services

Personal Voice Inc. can not and will not be held responsible for any failure on their part to achieve required results for any reason on behalf of client

Please enter the word that you see below.

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