Caregiver Questionnaire for Western New York Families

Finding the right care can feel like a lot to navigate. Tell Family Alliance of WNY what you or your loved one needs, and we will help you explore independent caregivers across Buffalo and Western New York whose experience, qualifications, and availability may be a good fit.

Tell Us About Your Caregiver Needs

Share only information relevant to the caregiver connection. Do not include Social Security numbers, medical records, financial account details, or other highly sensitive information.

Client Information

Tell us who needs support and how we can reach you.

Client First Name (required)

Client Last Name (required)

Email (required)

Client Cell Phone (required)

Client Address

Client City (required)

Client State (required)

Client Zip (required)

Client Advocate

Complete this section when another person is helping coordinate care.

Client Advocate First Name

Client Advocate Last Name

Client Advocate Address

Client Advocate City

Client Advocate State

Client Advocate Zip Code

Caregiver Preferences

List the days care is needed, then choose the typical start and end times. If the hours vary by day, include those details in the Days Needed field.

What are you looking for in a caregiver? (required)

Days Needed (required)

Typical Start Time (EDT) (required)

Typical End Time (EDT) (required)

Rate of Pay

Pay Type (required)

Private PayAgency Pay

Duties Expected (required)

Health & Dietary Information

Provide only the information that is relevant to the caregiver connection.

Health Issues

Allergies

Dietary Restrictions

By submitting this form, you allow Family Alliance of WNY to use the information you provide to respond to your request and help explore independent caregiver connections. Please review our Privacy Policy.

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