Contact form A notice! After completing the form, it will be sent to our office and subject to manual verification. Client Surname: First name: Street, No: ZIP / City: Phone: E-mail: Fax: The person/persons to be cared for IndividualCouple Surname: Street, No: ZIP / City: Phone: Fax: Birthday: Place of birth: Nationality: Knowledge of other languages: Who is the invoice recipient The following illnesses/disabilities/restrictions are present Health impairments: mentally and physically fitmentally fit and physically illmentally ill and physically fitmentally and physically ill Additionally please indicate: can walk alone: yesno can run with help: yesno Wheelchair: yesno Bedridden: yesno can go to the toilet independently: yesno Partial incontinence: yesno Total incontinence: yesno Care level: 123norequested Height: Weight: KIs there an outpatient nursing service? If so, how often and what tasks are performed? The following activities are necessary. Please provide a precise description and, if possible, a rough daily routine Working hours/duration Is night duty necessary, and if so, to what extent? Time off in lieu (e.g. hours/day) When should the assignment take place? Estimated duration of the assignment: Space for further details or for wishes regarding the qualification and characteristics of the strength to be conveyed and special requirements for the strength (e.g. age, strong person, non-smoker, driver's license, hobbies, love of animals, etc.) Additionally please indicate: FemaleMale Knowledge of German: Basic knowledgeAdvanced knowledge (understanding well, speaking with difficulty)Good knowledge (simple conversations are possible)Very good knowledge (conversations are possible without restrictions) Description of the accommodation (location, size, facilities, etc.) Are there pets in the household? Other communications, questions or comments I declare that I have read the regulations and accept them. I declare that I have read the privacy policy.