Old Folks Helper Application

P.O. Box 1075 -Beaverton, Or  97005

Name ________________________________     Contact Phone ____________________

Address _____________________________  City _________________   Zip _________

Client(s) age ____

Services requested: ________________________________________________________

Days of the week and times that work best: ____________________________________

Meal Planning: (foods you would like prepared, be specific: _______________________

_______________________________________________________________________

_______________________________________________________________________

Any food allergies or other allergies I should know about: ________________________

Will you be interested in shopping trips?  ______ Preferred store __________________

Disclosure Statement: (Please read and Sign):

I ___________________ the undersigned am contracting for personal care services from
Phoenix Turley (aka: Old Folks Helper). Ms. Turley has stated that she is a light duty personal assistant; light house-keeping, cook and shopping companion and I know that she I not a licensed medical professional and that I am hiring her only for the above mentioned personal services only.   She will not be lifting, bathing, administering medications or taking personal responsibility for individual care.

__________________________________        ______          ___________________
                        Signature                                      Date                 Relationship

Person responsible for account (if different): ________________________

Address ____________________________   City______________  State _____  Zip ___

• If you are ordering services for someone else and paying on-line, I will need an email from you with front and backside of your drivers license (verifying id) mailed/emailed before billing can commence.

Questions and Answers:

Q: What Services will you provide?
A:  I will do light duty house-keeping, cook meals, clean kitchen, run laundry, bring in mail, and drive you to errands.  This includes loading/unloading groceries and putting things away.

Q: What about Gardening?
A: That falls under a different category.  We offer gardening services, at $30. hr. (two person crew) through Grandma’s Gardener. (www.grandmasgardener.com) Services for gardening are not scheduled at the same time as personal services.

Q: What is your process?
A:  First off, these services are for folks 55 years or older.  If we were working for younger folks our rates would be higher.  You need to fill out an application, either in person or by mail.  We can mail applications to you or you can download forms off of our web site.  Once an application is completed we will give you a personal reference sheet and offer to schedule a first visit.   All fees are payable at the beginning of or prior to all visits.  That way the business end is out of the way.  We will only be able to stay for the scheduled time, we have other time commitments as well. 

Q: Where do you work?
A:  We work in West Portland and Beaverton only.  This is due to proximity to home, and not wanting to spend a lot of time driving to unfamiliar areas.

Q: Can I schedule for my loved ones?
A:  Yes you can, and we can set up independent billing, but you will need to submit identification prior to any billing or scheduling, and your folks will still need to sign the application, stating that they understand what I am there to do for them.

Q: Are there restrictions on scheduling?
A:  There is a two hour minimum on scheduling and a four hour maximum.  This is a part time endeavor for me… and I want it to be enjoyable for all people involved.

Any other questions:  Please feel free to contact me by phone, mail or email at any time.
Thank you for your interest and have a great day.