Polish Helping Hands, 15 New Britain Ave, Unionville, CT 06085, ph: 860-404-0499; fax: 860-404-0465
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Questionaire

Referred By: Date: mm/dd/yyyy
Name of Caller:
Phone Number:
Address:
City:

State:    Zip:
E-mail
Cleaning   Elderly Care   Nanny
Date of Appointment or Interview: mm/dd/yyyy

Tu  Th  Sa  Su

Information:

Start Date: mm/dd/yyyy
Hours:
Days:
Cleaning  Shower  Meal  Driving App  Dress  
Grocery  Remind of Med  Laundry  Exercises  
Salary:
English Speaking:
Yes No
Car Needed:
Yes No
Age Preference:


FOR NANNY
Ages of Children:
1
2
3

FOR ELDERLY
Name of Client:
Age:
Address:
Phone:
City:

State:    Zip:
Medical Conditions:


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