Let’s work together

Below are the client registration forms that we use to gather information about your children’s ages, interests, routines, as well as your family’s schedule and what you’re looking for in a candidate.

Client Registration Forms

Client Registration - Nanny

Name

First Name

Last Name

Phone

(###)

###

####

Address (city & zip code):

Have you ever worked with an agency before?

Have you ever employed someone in this role before?

When is your ideal start date?

What is your preferred pay rate?

Live-in or Live-out:

If live-in, include accommodations

What days and hours will the nanny be required to work?

We can assist with a schedule based on your specific needs

How would you describe your ideal nanny’s caregiving style? (e.g., nurturing, structured, playful, educational)

Please describe your children’s typical daily schedule (meal times, nap times, and any specific activities or routines):

Does your child(ren) have any allergies, medical conditions, or special needs?

What values are most important to your family? (e.g., respect, kindness, independence)

What duties would you like the nanny to perform? (Check all that apply)

Childcare (supervision, playtime, etc.)

Meal preparation for children

Light housekeeping (cleaning up after children, laundry)

Driving children to/from school or activities

Help with homework

Overnight care

Is there anything else you would like us to know to help us find the perfect nanny for your family?

Will the nanny need to drive the children? If so, will a car be provided, or should they use their own?

This form is for initial consultation purposes and does not constitute a formal agreement for services.

Client Registration - Special Needs

Name

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Preferred Contact Method:

Phone

Text

Other Household Members (Names/Ages/Relationship):

Pets in the Home (Type & Number):

Child's Information

Childs's age:

Diagnosis/Medical Condition(s):

Allergies or Dietary Restrictions:

Mobility Needs (Wheelchair, Walker, Assistance Required):

Communication Abilities (Verbal, Non-Verbal, AAC Device, Sign Language, etc.):

Behavioral Considerations (Triggers, Calming Strategies, Behavioral Plans):

Daily Routine (Sleeping, Eating, Activities):

Therapy or Treatments (PT, OT, Speech, ABA, etc.):

Care Needs

Personal Care Assistance Required (Dressing, Feeding, Toileting, etc.):

Preferred Activities/Hobbies:

Social Preferences (Enjoys Group Activities, Prefers One-on-One, etc.):

Safety Concerns (Wandering, Sensory Sensitivities, etc.):

Transportation Needs (School, Therapy, Social Activities):

Caregiver Expectations

Pay Range:

Preferred Start Date:

Desired Schedule (Days & Hours):

Primary Responsibilities Expected:

Preferred Caregiving Approach/Philosophy:

Additional Household Responsibilities (Light Cleaning, Meal Prep, Laundry, etc.):

Certifications or Training Required (CPR, First Aid, Special Needs Experience, etc.):

Line

Any Additional Notes or Special Requests:

This form is for initial consultation purposes and does not constitute a formal agreement for services.

Not sure of what your needs are?

We can help you determine the perfect role to meet your specific needs.

Schedule a no-obligation consultation today!

Book Now!

Let’s work together

Below are the client registration forms that we use to gather information about your children’s ages, interests, routines, as well as your family’s schedule and what you’re looking for in a candidate.

Client Registration Forms

We will be in touch with you as soon as possible after receiving this form!

We will be in touch with you as soon as possible after receiving this form!

Not sure of what your needs are?

We can help you determine the perfect role to meet your specific needs.

Household Harmony Agency LLC

Contact:

Service Areas: