Family Care Plan Questionnaire

Share what matters most about your loved one so we can reduce the stress of finding the right care.

You may skip any question you prefer not to answer. Only the final acknowledgment section is required.

About Your Loved One

Full name

Preferred name

Pronouns

Date of birth or age

Where they live

Your relationship to this person

What Matters Most Right Now

Current care priorities

Recent changes in health or daily life

Personality & Communication Style

Personality traits

How they like to communicate

Names and Forms of Address

Preferred titles or forms of address

Names or terms to avoid

Health, Safety, and Comfort Considerations

Health considerations (non-medical)

Mobility and safety notes

Comfort needs

Your Loved One's Everyday Life

Help us understand your loved one's daily rhythm, routines, and what feels normal for you.

Morning routine

Daytime activities

Evening routine

Sleep preferences

Your Loved One's Things That Bring You Joy

Hobbies and interests

Favorite activities

Music, shows, or media you enjoy

Food, Comfort, and Mealtime Traditions

Favorite foods and drinks

Dietary needs or restrictions

Mealtime traditions or preferences

Culture, Faith, and Personal Traditions

Cultural background

Faith or spirituality

Traditions that matter to you

Family, Community, and Belonging

Important relationships

Community connections

Social preferences

Your Loved One's Right Kind of Connection

Qualities that matter in a caregiver

Preferred communication style

Pace and personality fit

One More Thing

What should a new caregiver know about you?

Communication Preferences

Preferred contact method

PhoneTextEmailIn-app messaging

Best time to reach you

Emergency contact name

Emergency contact phone

Emergency contact relationship

Caregiver Matching Preferences

Qualities that matter

Gender preference

Language preference

Age range preference

Smoking or fragrance sensitivity

Pet-related preferences

Transportation needs

Schedule preferences

Boundaries and Household Expectations

Household rules or expectations

Privacy boundaries

Family Communication and Coordination

How often you want updates

Preferred update channel

PhoneTextEmailIn-app messaging

Who should receive updates

Primary decision-maker if loved one cannot respond

Emergency contact name

Emergency contact phone

Emergency contact relationship

Acknowledgment & Consent

Please review and sign below. This section is required to submit your questionnaire.

I understand that Senioritis is a technology-enabled matching platform and not my employer or care provider.

I understand that caregivers are independent service providers, not Senioritis employees.

I understand that a match is not a guarantee of employment, availability, compatibility, or outcome.

I understand that Senioritis and caregivers do not replace medical professionals or emergency services.

Full legal name (e-signature) *

I agree to the Senioritis Terms and Privacy Policy and confirm this Family Care Plan questionnaire submission.

By signing, you agree to our Terms and Privacy Policy.