Intake Form

The queen (♕, ♛) is the most powerful piece in the game of
chess. It can move any number of squares vertically, horizontally or
diagonally, combining the powers of the rook and bishop. Each
player starts the game with one queen, placed in the middle of the
first rank next to the king.
Home Care is a Chess Game; Your Scheduler, Recruiter, On-Call Team, or General Administrative team should be able
solve problems quickly and logistically.

They should be able to predict as much as they can the consequences of each of
their actions and how each step they take can affect the entirety of their team.

Home Care Admin Experts Intake Form

Please fill out the information below and provide as many details as possible to be able to provide you with an accurate quote on all our home care solutions.

If you have any questions regarding our solutions, please refer to our Client Handbook
or speak with your designated representative. All information relayed on this form will remain private.

Agency Name and LLC If Applicable

Date

Phone Number

Address. Please include City, State, and Zip Code

Number of ACTIVE Clients and Avg. Bill Rate

Number of Average Billable Hours PER WEEK (Last 4 weeks)

Number of ACTIVE Caregivers and Avg. PAY Rate

Do you accept Medicaid/Medicare/VA/TBI Insurance or programs, if so list them:

Hours of Business Operations in EST

List All Holiday or Days Of Year Business Office is Closed:

Who handles your after hours service inquiries if a potential client calls?

MATCHING YOU WITH THE BEST EXPERT FOR YOUR NEEDS IS IMPORTANT. BE PATIENT WE ARE ALMOST DONE!

KEY PERFORMANCE INDICATORS

How long has your most senior caregiver been with you?

How long has your most senior office staff member been with you?

How many new hires do you hire per week:

How many new clients do you start per week?

How many caregivers do you terminate per week?

How long has your office been open?

CALL VOLUME

When Calling Your Office Do you have a prompt for each department?

Estimate Number of Calls Per Day During Business Hours

Estimate Number of Calls Per Week When Office is closed and CALL offs

ORIENTATION AND RECRUITING

On a Scale from 1-10, Rate your Caregiver's Accountability:

Do you have experience recruiting virtually?

Are your caregivers trained on electronically clocking in and out?

Describe your orientation process in detail if interesting in recruiting services:

COMMUNICATION

Do you accept Text Messages from Clients and Caregivers to Communicate After hours?

Do you allow NON-emergency calls after hours?

Are you opposed to informing caregivers to minimize contacy for any reason other than a change in client condition, fall, or 911 inspired emergencies from 12am-6am?

ON-CALL PHONE NUMBER:
We will provide you with a phone number to forward all your calls to during business hours. Please provide the AREA code you would like us to use if we are providing ON-CALL SERVICES. An additional charge on service is a charge per number at $47.00 per month.

RECRUITING NUMBER:
Recruiting Services are conducted during business hours from our private recruiting line, and we do not require a new number for Recruiting Services.

SCHEDULING AND VIRTUAL ASSISTANCE (DURING BUSINESS HOURS):
Remote Daytime Schedule Or VA Services: During Business Hours only; If we are scheduling for your company- We will use YOUR VOIP system and will be making calls as if from office and as if in office.

Which VoIP system do you currently utilize? (We recommend RingCentral or Unite)

CONFIDENTIALITY NOTICE: This information/email/sheet, including all attachments, is for the sole use of the intended recipient(s) and may contain confidential information. Any unauthorized review, use, disclosure, alteration, or distribution is strictly prohibited and may violate state or federal law.

Please Print Your First, Last Name, and Title

Signature

Thanks! We’ll send you a qoute within 24-48 hours after an initial consultation.

(727)914-9189

info@iheart-hc.com

Our Company is based out of Florida,USA

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