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Holistic Health Care in Bermuda

44 Point Finger Road, Paget, Bermuda DV04 • (441) 296-7296

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Caregiver Services Request

Caregiver Request Form

Please use this form to tell us a little about your needs so that we can find you a caregiver that is suitable.

Step 1 of 4

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Name*
First Last
Address*
Street Address Apt. # Parish ZIP / Postal Code Country
Email*
Phone*
Who Needs the Caregiver?*
- For Myself
- A Family Member
- More than one (1) Family Members (in the same house)
- Someone Else
Name of Individual*
First Last
Name of Family Member*
First Last
Name of Family Member 2*
First Last
Is the Address of Family Member Different from yours?
- YES
- NO
Address where care will be administered*
Street Address Address Line 2 City ZIP / Postal Code Country
Address of Family Member(s)*
Street Address Apt. # Parish ZIP / Postal Code Country
Direction to the Home/Place where Care will be rendered*
Please list any land marks e.g. gas station, intersection, laundry mats etc.
Individual's Age
Your DOB*
MM slash DD slash YYYY
Family Member DOB*
MM slash DD slash YYYY
Family Member 2 DOB*
MM slash DD slash YYYY
Your Gender*
- Female
- Male
Family Member's Gender*
- Female
- Male
Family Member 2's Gender*
- Female
- Male
Gender*
- Male
- Female

Type of Caregiver Service Needed
- Full-Time
- Part-Time
- On-Call
- On-Demand
- Respite
- Live-In
Select as many as your needs require
What is your Maximum Budget?
This does not mean that we will try to exhaust your budget, it only gives us the opportunity to propose to you the best options available to you.
Full-Time Caregiver
Full-Time constitutes 40 or more hours per week for an extended period of six (6) or more months.
Start Date*
Tell us when would you like the caregiver to begin
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Part-Time Caregiver
Our Part-Time Services are for persons and families who are looking someone to cover a couple of hours per day, or few days per week amounting to less than 40 hours per week.
Start Date*
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Respite Caregiver
This service is for families who deserve to take that long overdue family vacation but have not been able to due to the round-the-clock demands from attending to the needs of their loved one. Now you can take that well needed vacation and let BEAMS take good care of your loved one while you are away. Just tell us a little about your needs and we will handle the rest
Start Date*
Tell us when you want the caregiver to begin
MM slash DD slash YYYY
End Date
Tell us when the caregiver will finish
MM slash DD slash YYYY
Please gives us at least one emergency contact in the event of an emergency while you are away.
Emergency Contact Name*
First Last
Relationship*
Emergency Email*
Primary Emergency Phone*
Secondary Emergency Phone
On Call Caregiver
Our On Call services are for those who need a caregiver within a short turnaround time and for special circumstances (weekend or holiday) amounting to less than one month of service. Please give us between 1 week and 48 hours notice.
Start Date*
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
On-Demand Caregiver
Do you have an EMERGENCY and need a caregiver right away? Complete this section and submit right now or give us a call at (441-534-5263) and we will have someone available for you within in less than 24 hours
Start Date*
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Live-In Caregiver
Our Live-In Services offer two options for caregivers (1) One (1) Caregivers covering 24 hour shifts with two off days or two (2) Caregivers covering 12 hour shifts (a daytime caregiver and a nighttime caregiver). Our Live-In Rate Includes the following: • One Full-Time Live-in Caregiver to work 5 days per week (8am-8pm), plus on call 7 nights per week. • One Alternate Caregiver to cover two twelve-hour shifts per week (8am-8pm) on the regular caregiver’s days off. • Sick, Vacation and other emergency coverage • Replacements/Reassignments • Processing of Work Permit Application (renewal) if required • Advertising for the position in local news papers (if required) • One Complementary Annual In-Home Doctor’s visit from our In-house Doctor • Direct 24 Hour access to our Doctor by the Caregiver • All other Administrative Costs
Start Date*
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Days & Times
Please select the Days & Times when you will need the caregiver. NB: THE MINIMUM HOURS PER DAY IS 3 HOURS
Select Week Days Needed*
- Sunday(s)
- Monday(s)
- Tuesday(s)
- Wednesday(s)
- Thursday(s)
- Friday(s)
- Saturday(s)
Sunday Begin Time*

: Hours

Minutes

AM/PM
Sunday End Time*

: Hours

Minutes

AM/PM
Total Hours - Sunday(s)*
Please enter a number greater than or equal to 3.
Monday Begin Time*

: Hours

Minutes

AM/PM
Monday End Time*

: Hours

Minutes

AM/PM
Total Hours - Monday(s)*
Please enter a number greater than or equal to 3.
Tuesday Begin Time*

: Hours

Minutes

AM/PM
Tuesday End Time*

: Hours

Minutes

AM/PM
Total Hours - Tuesday(s)*
Please enter a number greater than or equal to 3.
Wednesday Begin Time*

: Hours

Minutes

AM/PM
Wednesday End Time*

: Hours

Minutes

AM/PM
Total Hours Wednesday(s)*
Please enter a number greater than or equal to 3.
Thursday Begin Time*

: Hours

Minutes

AM/PM
Thursday End Time*

: Hours

Minutes

AM/PM
Total Hours - Thursday(s)*
Please enter a number greater than or equal to 3.
Friday Begin Time*

: Hours

Minutes

AM/PM
Friday End Time*

: Hours

Minutes

AM/PM
Total Hours - Friday(s)*
Please enter a number greater than or equal to 3.
Saturday Begin Time*

: Hours

Minutes

AM/PM
Saturday End Time*

: Hours

Minutes

AM/PM
Total Hours - Saturday(s)*
Please enter a number greater than or equal to 3.
Total Hours Per Week*
Type of Arrangement*
- Hourly Arrangement
- Live-In Arrangement
- Two Caregivers (12 Hrs Shifts)
- One Caregiver (24 Hrs Shift)

Qualifications Needs
Please use this Section to tell us more about your needs qualifications and experiences that you are looking for in a caregiver.
Your Preference(s) for Caregiver Qualification*
If your insurance company covers this they may require you to have a certified caregiver
- Certified
- Uncertified
Your Preference(s) for Caregiver Experience*
- 0-2 Years Experience
- 2-5 Years Experience
- Over 5 Years Experience
- Dementia/Alzheimer's Care Experience
- Stroke Patient Experience
- Paralyzed Patient Experience
- Other
Other Caregiver Preferences*
Please enter all preferences you require
Do you have Caregiver Coverage from your Insurance Provider?*
This will help us to get you the necessary documentation required by your specified Insurance Provider to facilitate your reimbursement.
- Yes
- No
Who is your Insurance Provider*
Select as many as applied to you
- Select All
- BF&M
- Future Care/GHI
- WarVet
- Financial Assistance
Type of Coverage*
Please enter the type of coverage you are allowed and how many hours per week and amount per hour. E.g. Personal Care, 40 hours, $15 per hour. You can use the + button to add as many types of coverage
Type of Care Number of Hours Per hour rate
Policy Number
The policy number can be found at the top of the Future Care Approval Letter. This is required to calculate rates.
Hidden
Who is your Insurance Provider*
Please describe coverage including amount (per month or week)?*
Upload Approval Documents?
You can upload any documents for your insurance provider confirming coverage for homecare.
Max. file size: 100 MB.
In Case of an Emergency Would you like us to contact your GP or Dentist?*
- Yes
- No
Please select which*
- GP
- Dentist
You may choose more than one
GP Name*
First Last
GP Phone*
Dentist Name*
First Last
Dentist Phone*

Responsibilities & Duties
Please select the responsibilities and duties that caregiver will perform as well as other things the caregiver will need to know about the working environment such as pets etc.
Responsibilities*
Here are some of the things you will be responsible for during this job:
- Social Pursuits
- Bedroom
- Personal Care
- Meals and Nutrition
- Health Care*
- Providing Transportation*
Select Which Bedroom duties will be required of the caregiver*
check all that applies
- Help with getting in and out of bed
- Straighten room
- Change bed sheets
- Other
Other Bedroom*
Select Which Social Pursuits will be required of the caregiver*
check all that applies
- Going on walks or sitting outside
- Playing card or board games
- Reading out loud
- General companionship and conversation
- Other
Other Social Pursuits*
Select Which Personal Care will be required of the caregiver*
check all that applies
- Assist with transfers from chairs, toilet, bath, etc
- Assist with toileting
- Assist with walking
- Assist with personal grooming
- Assist with bathing
- Assist with dressing
- Assist with exercises
- Observe and record any health or behavior changes
- Other
Other Personal Care*
Select Which Meals and Nutrition Care will be required of the caregiver*
check all that applies
- Assist with feeding
- Wipe counters and stove
- Prepare and serve food
- Clean, dry and put away dishes
- Grocery shopping
- Other
Other Meals and Nutrition*
Select Which Health Care will be required of the caregiver*
These services are required to be provided by a licensed therapist or nurse and will be provided at an additional cost and upon the availability of a licensed therapist or nurse.
- Speech therapy
- Rehabilitative or therapeutic physical
- Medication prompting
- Wound care or bandaging
- General dusting and cleaning of home surfaces
- Occupational therapy
- Other
Other Health Care*
Select Which Transportation needs will be required of the caregiver*
*If a vehicle is not provided, any miles driven while on the clock using the employee’s car will be reimbursed at the Rate of $10-$25 per day (depending on the distance and number of errands covered per day). This covers the cost of gasoline, as well as general wear and tear on the vehicle. Employee will maintain and mileage log and submit to employer for reimbursement at the end of the pay period.
- Employee will be provided a vehicle
- Social visits to family and friends
- Medical and dental appointments
- Arranging for alternative transportation
- Beauty or personal care appointments
- Faith-based events
- Other
Other Transportation Care*
Additional Information/Needs/Requirements for the person requiring care*
Use this box to tell us anything that you believe is important for us to know about you or your loved ones needs, requirements, conditions, mental and physical condition, prescription medications etc.
Is Lifting involved*
- Yes
- No
Please Explain*
Use this explain the type of lifting involved
Are there Pets in the home?*
- Yes
- No
Type of Pets*
- Cat(s)
- Dog(s)
- Other
Please list Type(s) or Pet(s)*

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Home
About Us
Functional Medicine
Services
BEAMS Home Care Services
Resources

Office Hours

Monday

8:00 AM - 4:00 PM

Tuesday

8:00 AM - 4:00 PM

Wednesday

8:00 AM - 5:00 PM

Thursday

8:00 AM - 4:00 PM

Friday

8:00 AM - 2:00 PM

Saturday

Closed

Sunday

Closed

1-441-296-7296

44 Point Finger Road
Paget, Bermuda DV04

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Bermuda Alzheimer & Memory Services • 44 Point Finger Road, Paget, Bermuda DV04 • (441) 296-7296
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