Caregiver Intake Form

Full Name *

This field is required.

Email *

This field is required.

Phone Number *

This field is required.

City/State

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Zip Code

Preferred Contact Method *

This field is required.

Upload Profile Photo *

Profile Photo Guidelines: Please upload a clear, recent photo of yourself only (no group photos). Photo should be well-lit, professional, and front-facing. Recommended size: 800 × 800 pixels (square). File types: JPG or PNG. Max file size: 5MB.

Click to upload or drag and drop

This field is required.

Are you an RBT or BT?

Upload Certificate

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This field is required.

Years of Caregiving Experience *

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Autism Support Experience *

Selections indicate personal experience only. Safe Hands Autism Care does not verify clinical qualifications or supervise caregiving services.

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HIghest Level of Education Completed

Education information is provided by the caregiver and is not independently verified by Safe Hands Autism Care.

Resume Upload

Upload your resume in PDF or Word format. Maximum file size: 5MB.

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Availability Type *

Full-time

Part-time

Occasional

After-school

Weekends

Evenings

Overnights

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Weekly Availability

Available for Same-Day Requests?

Citys/Areas Served *

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Maximum Travel Distance *

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Services You Provide *

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Age Groups Supported

Toddler (2–4)

Elementary (5–10)

Pre-teen (11–13)

Teen (14–17)

Adult 18+

Select all that apply

Optional Documentation Upload

You may upload documents such as training certificates, CPR/First Aid cards, resumes, or proof of completed coursework.

All documents are self-submitted and are not verified by Safe Hands Autism Care. Parents are encouraged to independently confirm credentials.

Click to upload or drag and drop

This field is required.

I understand that all certifications and training listed are self-reported and have not been independently verified by Safe Hands Autism Care.

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Reference Name: *

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Relationship to Caregiver

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Phone

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Email

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Reference Name: *

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Relationship to Caregiver

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Phone

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Email

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Short Bio *

This summary will be displayed on your caregiver profile.

This field is required.

Strengths as a Caregiver *

Highlight what makes you a great caregiver.

This field is required.

Additional Notes

This information will also be visible on your profile.

I understand that the information provided in this section will be publicly visible on my caregiver profile and consent to its display on the Safe Hands Autism Care platform.

This field is required.

I understand I am an independent caregiver, not an employee of Safe Hands Autism Care.

This field is required.

I acknowledge Safe Hands Autism Care is a referral service only.

This field is required.

I understand all agreements are between myself and the parent.

This field is required.

I confirm all information provided is accurate.

This field is required.

I consent to having my profile displayed to registered parents.

This field is required.

I agree to maintain confidentiality.

This field is required.

Signature *

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Date *

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Become a Safe Hands Caregiver

Step 1: Personal Information

Step 2: Profile Photo

Step 3: Background & Experience

Step 4: Availability

Step 5: Service Area

Step 6: Sevices Offered

STEP 7: SAFETY & TRAINING

STEP 8: REFERENCES

Reference 1

Reference 2

STEP 9: PROFILE PREVIEW & CONSENT

STEP 10: LEGAL AGREEMENTS (CRITICAL)

STEP 11: DIGITAL SIGNATURE

QUICK LINKS

CONTACT DETAILS

Step 1: Personal Information

Step 2: Profile Photo

Step 3: Background & Experience

Step 4: Availability

Step 5: Service Area

Step 6: Sevices Offered

STEP 7: SAFETY & TRAINING

STEP 8: REFERENCES

Reference 1

Reference 2

STEP 9: PROFILE PREVIEW & CONSENT

STEP 10: LEGAL AGREEMENTS (CRITICAL)

STEP 11: DIGITAL SIGNATURE

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