Carehack Cares Intake Form
Thank you for your interest in the Carehack Cares Care Provider Program. This form helps us learn about your child, family, and care needs so we can create a safe, supportive, and inclusive caregiver match.
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Email *

Parent(s)/Guardian(s) Name

Best Email + Phone Number to use for coordinate during the matching process

How many children/adults would you plan to need care? (child/adult with a disability and siblings) Please include ages.
Where are you located (county/part of town; example-"I live in East Nashville") *
How often would your family be interested in using Carehack Cares? *
What will a typical caregiver shift include? (meals, play, bedtime, etc.) *

Will medication be needed during care?

 *
Required
Do you have pets in the home? If yes, please list the type(s) of pets and anything a caregiver should know. *
What level of support would your child with a disability need? Are there any safety, medical, or sensory needs a caregiver should be aware of?  *
Does your child need assistance with toileting? *
Required
Is there anything about your home environment a caregiver should be aware of? (stairs, cameras, accessibility needs, allergies, etc.) *

What qualities or experience are important to you in a caregiver? Please anything you want us to know to make the best match?

 *
How did you hear about Carehack Cares? *
Do you have any other comments, suggestions, or questions? *
Carehack is committed to inclusive, respectful care. This information helps us create a safe, supportive match for your family. We will reach out to you within the next 48 hours.Talk soon. - Carehack Team
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