Consumer Application Service available only to residents of Los Angeles County. For additional information, contact us at 866-544-5742. **Fields marked with an asterisk are required. Consumer Application Step 1 of 3 - Page 1 0% Name* First Last Address* Street Address Address Line 2 City State Zip Phone*Email Date of Birth* Your Gender*Please selectFemaleMaleEitherWhat is your religion?Please selectBuddhistChristianCatholicIslamicJewishOtherWhat other religion?Emergency Contact / RelationshipEmergency Contact's PhoneHow did you hear about us?*Please selectHospital or Nursing Home ReferralOnline SearchSomeone I Know Uses the Homecare ExchangeIHSS RecommendationSocial MediaOtherPlease share how you heard about us?*I am a (Select One Option Below)*Please selectIHSS-Authorized Care RecipientPrivate Pay Care RecipientHow many hours do you estimate you will need a caregiver for yourself or a loved one per week?If You Selected IHSS-Authorized Care Recipient Above, Please Complete the Information Below (If You Are Private Pay, You May Skip This)Your IHSS Social Worker's NameYour IHSS Worker's PhoneYour IHSS Case NumberIHSS Case Number*How Many IHSS Hours Have You Been Approved?* Save and Continue Later Please Tell Us About Your Conditions & NeedsWhich of the Following Tasks do You Need Assistance Performing? (Select all that All That Apply)* Assistance Going to Doctor Appointments Ambulation Exercises Bed Baths Bowel Program Cleaning Cooking Dressing Errands Feeding Grooming Laundry Medication Dispensation Menstrual Care Prosthetic Assistance Protective Supervision Repositioning & Skin Care Service Animals Shopping Wheelchair/Walker Assistance Which of the Following Conditions or Medical Needs Apply to You? (Select all that All That Apply)* Alzheimer's Disease Arthritis Asthma Cancer CPR Dementia Diabetes Heart Condition HIV/AIDS Hypertension Mental/Emotional Disability Multiple Sclerosis Paralysis Parkinson's Disease Range of Motion Issues Respiration Assistance Seizures Special Diet Spinal Bifida Spinal Cord Injury Stroke Thalamic Brain Injury Visual Impairment Vital Sign Monitoring Wound Care Other For what other conditions do you need assistance?*Please describe any special dietary needs?If You Require a Provider with Additional Skills, Please Specify BelowWhat language do you need your care provider to speak?* English Spanish Armenian Korean Tagolog Mandarin Cantonese Other What language do you require your provider to speak?Which gender do you prefer for your care provider?*Please selectFemaleMaleEither is FineDo You Need Your Caregiver to Have a Car & Provide You With Transportation?*Please selectYesNoDo You Require a Care Provider That Will Refrain From Wearing Scented Fragrances on the Job?*Please selectYesNoDo You Have a Dog?*Please selectYesNoDo You Have a Cat?*Please selectYesNoAre You a Smoker?*Please selectYesNoDo You Allow Others to Smoke in Your Home?*Please selectYesNoWhich of the Following Days & Times Do You Need a Caregiver to Provide Assistance to You?Sunday* Morning Afternoon Evening Overnight All N/A Monday* Morning Afternoon Evening Overnight All N/A Tuesday* Morning Afternoon Evening Overnight All N/A Wednesday* Morning Afternoon Evening Overnight All N/A Thursday* Morning Afternoon Evening Overnight All N/A Friday* Morning Afternoon Evening Overnight All N/A Saturday* Morning Afternoon Evening Overnight All N/A Save and Continue Later How Would You Like to Be Connected with a Provider?I Would Like the Homecare Exchange to Provide Me with the Names & Phone Numbers of Care Providers so I Can Contact Them Myself*Please selectPlease Mail InformationPlease E-Mail InformationPlease Call With the InformationI Authorize the Homecare Exchange to Give Out My Name and Phone Number?Please selectYesNoThis Agreement contains important provisions regarding the nature of Homecare Exchange services, the Independent Provider Mode, the duties of Homecare Exchange participants, and the Release of the Homecare Exchange, its affiliates and agents from any liability. Homecare Exchange 1. Nature of Homecare Exchange Services: SEIU Local 2015, provides this Union Provider Homecare Exchange at no cost to the provider or care recipient, for the express purpose of facilitating and/or assisting in the development of the employment relationship between the provider and potential care recipient. However, the decision of whether to employ any potential provider applicant is solely at the discretion and control of the care recipient. Homecare Exchange services are entirely optional and voluntary. The Homecare Exchange shall require that all provider applicants comply with all state laws and regulations required for their services as a provider (including all required background checks). However, the Homecare Exchange is not responsible for any further or independent verification of whether the provider has actually met all the conditions, beyond the normal presentation of documents indicating that such requirements have indeed been met. Beyond this initial screening process, the Homecare Exchange does not perform any additional evaluation, interviews, or other means of verify or vouching for the quality of the provider Homecare Exchange applicant. Therefore, it is essential that the care recipient conduct his/her own evaluation of the provider prior to establishing the employment relationship. Further, the Homecare Exchange does not warrant the quality of the applicant or his or her abilities to carry-out the duties required by the care recipient. The Homecare Exchange will, however, conduct some limited matching of the provider to the stated needs of the care recipient profile. Any care recipient and applicant provider therefore must use their own judgment and make their own decisions regarding one another’s skills, character and compatibility, and as to how well they may meet each other’s needs. The care recipient and provider assume and accept the risk of such decisions. 2. Independent Provider Mode of Service: When a care recipient offers employment to a provider, and the provider has accepted such employment the provider becomes the care recipient’s employee. In accordance with the law and County DPSS requirements and guidelines, the care recipient has sole authority to hire, assign hours and duties, direct the work, supervise, evaluate, and choose whether to continue or terminate the provider’s services. Likewise, the provider retains the right to resign such employment at any time without notice or cause. The Homecare Exchange has no authority or responsibility for any such matters or for any injuries or damages which may arise out of the referral or which may arise out of the employment, or for investigating or resolving any disputes, misunderstandings or injuries which may arise between a care recipient and a provider or any third party. RIGHTS, RESPONSIBILITIES AND RELEASE (3) Receipt and Use of Personal Information. As part of its operations, the Homecare Exchange may seek and/or receive information concerning Homecare Exchange participants, including information furnished by the care recipient about his or her needs, or employment and personal information from references (or others) of a confidential or sensitive nature. The Homecare Exchange may share such information with others for Homecare Exchange purposes, or to investigate or act upon such information to grant or deny referrals, or to suspend, exclude or remove a provider or care recipient from Homecare Exchange participation, through confidential procedures. Any disputes concerning any such uses or related decisions are to be determined by the Homecare Exchange Management Committee. The decisions of the Homecare Exchange Management Committee are final and binding upon all concerned, including Homecare Exchange staff and any involved care recipient (s) and/or provider(s), and are not to be the subject of any further proceedings or litigation of any nature. 6. Participant Responsibilities: Homecare Exchange participant and services are a revocable privilege and not a legal right or entitlement. The Homecare Exchange Management Committee can terminate the participation of any provider or care recipient at any time it deems appropriate and necessary. Each participant (provider or care recipient) is expected and required, as an ongoing condition of Homecare Exchange participation: (a) To comply with all Homecare Exchange policies, procedures and directives, and to cooperate fully with Homecare Exchange personnel; (b) To pursue all referrals diligently, by prompt follow-up, to attend all agreed upon interviews and other appointments, and to keep the Homecare Exchange updated as to all decisions; and (c) To treat Homecare Exchange staff and all other Homecare Exchange participants with civility and respect. PARTICIPANT’S RIGHTS, RESPONSIBILITIES AND RELEASE (4) PARTICIPANT’S RELEASE: The undersigned Homecare Exchange participant hereby releases the Homecare Exchange from any claim, damages, injuries, liability or remedy of any nature relating in any way to the Homecare Exchange, its services or denial of services, or its actions or failures to act. This includes any injuries suffered while seeking employment or considering referrals, or while providing or receiving home assistance services or acting as employer of provider, the undersigned will not make any claims (or seek any remedy) against the Homecare Exchange. The above release applies to; Homecare Exchange, SEIU Local 2015, the County of Los Angeles, affiliated agencies such as those furnishing emergency/respite services to care recipients, the individual officers, governing board members, agents, employees, representatives, advisers, insurers and volunteers of the Homecare Exchange and of such related and affiliated entities, and each of them, and all entities and persons who have furnished information or otherwise cooperated with the Homecare Exchange. This release is made on behalf of the undersigned participant’s personal representatives, family, heirs, dependents, community property and assignees, as well as on the participant’s own behalf. (c) Nothing in the above release is intended to affect any rights or claims the undersigned may have against a provider or care recipient, or against any person or entity other than those Homecare Exchange-related ones described above. (d) If the undersigned is a provider applicant, this release does not affect any rights he or she may have either under the PASC-SEIU collective bargaining agreement or against the State of California under Workers Compensation or Unemployment Insurance laws. PARTICIPANT’S RIGHTS, RESPONSIBILITIES AND RELEASE (5) The undersigned has carefully reviewed and considered each and every one of the terms and conditions of this Agreement, understands them, and has decided voluntarily to agree with them. It is understood that the Homecare Exchange and its affiliates will rely upon this Agreement when granting Homecare Exchange participation and services to the undersigned Homecare Exchange participation.I agree to the Participant's Rights, Responsibilities, & Release as written above.*YesDid you fill out this form yourself or did a representative actin on your behalf complete this form?*I completed this form myselfI had a legal representative complete this form on my behalfIf you completed this form for another person, please let us know your name, relationship, and phone number.* First Last Relationship*Phone*PhoneThis field is for validation purposes and should be left unchanged. Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.