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Agate Healthcare Services connects clients with qualified independent caregivers throughout Southwest Florida. By registering, you can be considered for referral opportunities that align with your credentials, caregiving experience, availability, preferred service area, and the types of support you are prepared to provide.

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Your caregiver profile helps Agate identify potential matches based on each client’s requested services, schedule, mobility needs, equipment, household considerations, and caregiver preferences. You remain free to decide which referral opportunities you would like to consider.

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Registration does not create an employment relationship or guarantee that referral opportunities will be available.

Join Agate Healthcare Service's Caregiver Registry

Why Register with Agate?

For Caregivers

What You Can Expect

Our Registry

Registration helps Agate gain a clear understanding of your unique qualifications, experience, availability, and care preferences so we can thoughtfully match you with the most compatible client opportunities.

 

The more we know about you, the better we can align you with referrals that truly fit your skills, schedule, and preferred type of care.

Get Matched to
Real Opportunities

1

Your profile is reviewed against actual client needs—skills, experience, location, availability, and care requirements all matter.

2

Choose the referrals you want. Accept only the opportunities that fit your skills, schedule, and comfort level.

You Stay in Control

Know Before
You Accept

3

Every referral includes clear details—care needs, schedule, location, and expectations—so you can decide with confidence.

Show What You
Can Do

4

Build a strong profile that highlights your credentials, experience, specialties, availability, and preferred care settings.

Work Independently, On Your Terms

5

You provide care within your scope and judgment while maintaining full professional independence.

Stay Informed
and Ready

6

Agate keeps you updated on requirements, expiring documents, and new referral opportunities that match your profile.

Apply to Agate's Caregiver Registry

Ready to Join?

Caregiver Application

Part 1 of 4 - Applicant Information and Credentials

Complete the application below to tell Agate about your qualifications, caregiving experience, availability, preferred service area, and referral preferences. Questions marked with an asterisk (*) are required.


This online form is the first portion of Agate’s Caregiver Registration process. You may upload supporting documents to help expedite the review and registration process. Additional identity and screening information may be requested after the initial review.


All sensitive information will be collected through designated secure fields or secure submission methods within the application platform.

SECTION 1 - Contact Information
Have you ever used another legal, professional, or credentialed name?
No
Yes
Date of Birth
Month
Day
Year
County of Residence

Please use the email address just entered when completing Parts 2, 3 and 4 of the application.

Preferred Method of Contact
Phone call
Text message
Email
May Agate contact you by text message regarding your application and registration process?
Yes
No
Which languages do you speak? (Select all that apply.)
SECTION 2 - Previous History With Agate
Have you previously applied or requested registration with Agate Healthcare Services?
No
Yes
Have you previously accepted caregiver referrals through Agate Healthcare Services?
No
Yes
SECTION 3 - Caregiver Classification and Credentials
For which caregiver classifications would you like to be considered? (Select all that apply.)
What is your primary caregiver classification?
What type of primary license, certificate, or training credential do you hold?
Is this license, certificate, or credential currently active and in good standing?
Yes
No
Not Sure
Not Applicable
Which training or certifications have you completed? (Select all that apply.)
Have you completed a Florida Level 2 background screening?
Yes—through the AHCA Care Provider Background Screening Clearinghouse
Yes—through another organization
No
Not sure
Do you currently have documentation from a healthcare professional stating that you are free from signs and symptoms of communicable disease?
Yes—dated within the past six months
Yes—but it is more than six months old
No
Not sure
SECTION 4 - Professional Disclosures

A “Yes” response to any of the following does not automatically disqualify you. Agate may contact you for additional information or documentation.

Are you legally authorized to provide independent caregiver services in the United States?
Yes
No
Has any professional license, certification, registration, or credential you have held ever been denied, restricted, suspended, revoked, surrendered, placed on probation, or otherwise disciplined?
No
Yes
Are you currently the subject of an investigation or pending action by a licensing board, regulatory agency, healthcare organization, or professional organization?
No
Yes
Have you ever been excluded, suspended, or declared ineligible to participate in Medicare, Medicaid, or another government healthcare program?
No
Yes
Not Sure
Have you ever been removed from or asked to leave a healthcare, caregiving, or client-service position or arrangement because of alleged misconduct, abuse, neglect, exploitation, theft, fraud, dishonesty, or a client-safety concern?
No
Yes
Are you aware of any pending legal, regulatory, credentialing, or professional matter that could affect your eligibility to provide caregiver services?
No
Yes
Not Sure
Section 5 - Referral Source
How did you hear about Agate Healthcare Services?

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

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