Family Intake Form — CuraHome Care Co.

Section 1 — Parent / Guardian Information

First Name *

Last Name *

Phone Number *

Email Address *

Home Address *

City *

State / ZIP *

Is there a second parent / guardian in the household?

Yes No

Second Parent / Guardian Name

Second Parent / Guardian Phone

How did you hear about CuraHome?

If referred, who referred you?

Section 2 — Children in Your Home

Please fill in information for each child who will be in the caregiver's care.

Child 1

First Name *

Age *

Any allergies, medical conditions, or special needs?

Child 2 (if applicable)

First Name

Age

Any allergies, medical conditions, or special needs?

Child 3 (if applicable)

First Name

Age

Any allergies, medical conditions, or special needs?

If you have more than 3 children, please list their names, ages, and any relevant notes here

Section 3 — Care Needs & Schedule

Type of Care You're Looking For *

Nanny — Full-Time Nanny — Part-Time Babysitter (occasional) Date night / event coverage Not sure yet

Days Care Is Needed (select all that apply)

Typical Start Time

Typical End Time

Approximate Hours per Week

Desired Start Date

Will overnights ever be needed?

Yes No Occasionally

Will travel with the family ever be required?

Yes No Possibly

Budget / Hourly Rate Range *

Section 4 — Home & Household

Do you have pets?

Yes No

If yes, please describe (type, breed, temperament)

Will the caregiver be expected to drive your children?

Yes — in their car Yes — in nanny's car Both Not sure yet

Light household duties you'd expect (select all that apply)

Children's laundry Children's meals Tidying play areas School pickup / dropoff Activity transportation None beyond childcare

Section 5 — Caregiver Preferences

Do you have a language preference for your caregiver?

Is there anything specific you're looking for in a caregiver that we should know about?

Section 6 — Placement Tier

Select Your Placement Tier *

Standard

$6,000 – $8,000

· In-home family consultation
· In-person caregiver interviews
· Full vetting & background checks
· CuraHome present at your caregiver's first session
· We'll keep working until we find the right fit
· No ongoing support after placement

Family Application

CuraHome Care Co.

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