Consumer Partner Online Form

Last Name
First Name
Middle Inital

Home Address
City
State
Zip

Home Telephone

Email Address

Birth Date

In Case of Emergency Notify:
Name
Relationship
Telephone

Address

Special Abilities / Skills
Why do you need a personal assistant?

Personal Requirements for PAs while in your home. (For example, your smoking policy, phone usage, visitor policy, music/noise level preference).Peronal Requirements

How were you referred to PPA?

Do you have pets?
Please specify

Do you prefer same sex PAs or does it matter?

Personal References:1) Name
Phone

2) Name
Phone

Days & Hours Assistance is needed:

MorningMon
Tue
Wed
Thu
Fri
Sat
Sun



Mid dayMon
Tue
Wed
Thu
Fri
Sat
Sun



EveningMon
Tue
Wed
Thu
Fri
Sat
Sun



NightMon
Tue
Wed
Thu
Fri
Sat
Sun

Comments

We must have a copy of your job description (how/when you want the work done).Do you have a written job description?

If no, do you need assistance to write one?

How can we assist you with this?

Have you ever supervised PAs before?

How do you pay for personal assistance?
Privately
3rd party payer

What is your 3rd party payer?DHS
MI Choice
Private Insurance
WCHO
Other (please specify)

How much do you currently pay per hour?

Please type your full name below to acknowledge that all of the information provided is accurate.
Full Name