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For Caregivers

Apply to Agate's Caregiver Registry

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Caregiver Application

Part 2 has been submitted. Continue your caregiver application below.

Part 3 of 4 - Caregiver Matching Profile

Complete Part 3 by describing your caregiving experience, current availability, preferred service area, and the types of referral opportunities you would consider. Your responses will help Agate identify potential referrals that align with your qualifications and preferences. Questions marked with an asterisk are required.


All four parts of the online application must be submitted before the application is considered complete. Enter the same email address used in Part 1 so Agate can connect your submissions.

SECTION 1 - Application Identification
SECTION 2 - Caregiving Experience and Capabilities
Approximately how many years of caregiving, healthcare, homemaking, or companion-service experience do you have?
In which settings have you provided services? (Select all that apply.)
With which populations do you have experience? (Select all that apply.)
Which types of services are you currently qualified and willing to provide? (Select only services that are consistent with your current qualifications, training, credentials, and lawful scope.)
Which personal-care activities are you qualified and willing to assist with? (Select all that apply.)
Which homemaker or companion services are you willing to provide? (Select all that apply.)
Which mobility equipment or assistance methods do you have experience using? (Select all that apply.)
Which clinical or nursing services are you currently qualified and willing to provide? (Select only services that are within your current license, certification, training, and lawful scope.)
With which health conditions or care situations do you have experience? (Select all that apply.)
With which memory, cognitive, emotional, or behavioral situations do you have experience? (Select all that apply.)
Are you willing to consider referrals involving hospice or end-of-life support?
Yes
No
It depends on the individual referral
I would like additional information before deciding
SECTION 3 - Availability
When would you be available to begin considering referral opportunities?
Immediately
Within one week
Within two weeks
Within one month
On a specific date
I am not currently available

If you are not currently available, please answer the remaining questions based on the availability and referral arrangements you expect to consider in the future.

Which days are you generally available? (Select all that apply.)
Which hours or shifts are you generally willing to consider? (Select all that apply.)
Which types of overnight availability would you consider? (Select all that apply.)
Approximately how many hours per week would you prefer to make available for referrals?
What is the shortest referral or shift length you would generally consider?
3 hours
4 hours
6 hours
8 hours
12 hours
No minimum preference
Which types of scheduling arrangements would you consider? (Select all that apply.)
Would you consider live-in or extended-shift referrals?
Yes
No
It depends on the individual referral
Are you available on weekends?
Yes
No
Sometimes
Are you available on holidays?
Yes
No
Some holidays
Would you consider referrals offered on short notice?
Yes
No
It depends on the circumstance
SECTION 4 - Preferred Service Area & Transportation
In which counties are you willing to consider referrals? (Select all that apply.)
What is the maximum distance or travel time you would generally consider for a referral?
Up to 10 miles
Up to 20 miles
Up to 30 miles
Up to 45 miles
More than 45 miles
Depends on the referral
No specific limit
How would you generally travel to a client location? (Select all that apply.)
Do you have a current, valid driver’s license?
Yes
No
Do you have regular access to a vehicle with current automobile insurance?
Yes
No
Not Applicable
Which client-transportation services would you consider providing? (Select all that apply.)
SECTION 5 - Referral and Matching Preferences
In which locations are you willing to consider providing services? (Select all that apply.)
Which statement best describes your preference regarding personal-care services for clients of different genders?
I am willing to provide personal care to clients of any gender
I prefer to provide personal care to female clients
I prefer to provide personal care to male clients
It depends on the individual referral
I do not provide personal-care services
Are you willing to consider referrals in homes with pets?
Yes
No
It depends on the type of pet
Are you willing to consider referrals in homes where smoking occurs?
Yes
No
Only if smoking does not occur while I am present
It depends on the circumstances
Are you willing to consider referrals in homes where stairs must be used?
Yes
No
It depends on the number or type of stairs
Are you willing to consider referrals that involve infection-control precautions?
Yes
No
It depends on the individual referral
I would like additional information before deciding

Information submitted through this form will be handled in accordance with Agate Healthcare Services’ Privacy Policy.

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