1. How do I become a caregiver in Los Angeles?

California state law mandates caregivers to have 10 Hours of Professional Caregiver Training. You can take the course to meet the California state law guidelines.

2. Do you need a license to be a caregiver in California?

There is no need for a license for privately paid caregivers in California.

3. Can Prime caregivers help me find employment as a caregiver?

Yes, Prime caregivers is a referral employment agency. You can fill out the form to schedule an appointment.

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Client Information Form

Home > Client Application

Thank you for your interest in Prime Caregivers. Please complete this form so we can get the required information about your case and begin a care plan. We will get back to you as soon as possible.

Client's Name *

First

Last

Opt in To Text Messages *

Yes
No

Recieve Information about Your Case

Phone Number

Recieve Messages About Your Case

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact Information

Emergency Contact Name *

First

Last

Phone *

Relationship *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact Name *

First

Last

Phone *

Relationship *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Client Information

Gender *

Male
Female

Age *

Weight *

Height *

What is the clients preferred language?

English
Spanish
Other

Please list preferred languages

What is the clients current diagnosis *

Primary Physician's Name *

First

Last

Primary Physician's Phone Number *

Primary Physician's Address

Address Line 1

Address Line 2

City

State

Zip Code

Does the client live in a *

Home
Aapartment
Other

What floor? *

First Floor
Second Floor or Higher

Can the client walk? *

Yes
With Assistance
No

Does the client ?

Use a wheelchair
Use a cain
Use a walker

Is the client bedridden? *

Yes
No

Is the Client? *

Alert
Disoriented

Please Explain

Does the client have?

A history of stroke
Alzheimer's
Dementia
Trouble sleeping at night
Diabetes
A catheter
Diapers
Oxygen/Breathing Machine

Does the client smoke? *

Yes
No
Sometimes

Services Needed

The Client needs a *

Live IN Caregiver
Live Out Caregiver
Hourly

How many hours per week? *

0-20 Hours a week
20-40 Hours a week
40+

What Hours *

Day (8am-4pm)
Evening (4pm-12am)
Night (12am- 8am)

For a Live-In Caregiver, Do you have

A room for the Caregiver
Wifi
TV in the Caregivers Room
A baby monitor for the Caregiver to monitor the client at night

If there is no private room for the caregiver, Please explain the sleeping situation

What services does the client need? *

Driving
Light Housekeeping
Cooking/Dietary
Laundry
Daily Living Essentials
Ambulatory/Assistance with moving
Reminders
Other

Whose car will be driven? *

Caregivers Car
Client's Car

Select Daily Living Essentials Needing Assistance *

Bathing
Oral Care
Dressing
Makeup/ Hair Care
Toilet
Other

Please Explain

Are there animals in the house? *

Yes
No

What kind? *

Dog
Cat
Other

Please Explain

Payment and Insurance

Who will be paying for services?

Insurance
Private Pay
Other

How would you like your bill sent to you?

Paperless/ Internet bill
Paper bill through USPS

Comment

We Believe Everyone
Deserves a Quality Care

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Prime caregivers believes in lending the support and home care assistance to adults and seniors in Southern California to make lives better.

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We Believe Everyone
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