New Client Intake Thank you for choosing Southwest Domestics Contact Service Schedule Household Details Please fill in all required fields below. Contact InformationLet's start with your basic details Email * Please enter your email Full Name * Please enter your full name Address * Please enter your address Zip Code * Please enter your zip code Cell Phone * Please enter your phone number Home Phone Work Phone How did you hear about us? Google Radio Facebook Friend Other Continue Service DetailsTell us what type of care you need Service Requested * Nanny Housekeeper Nanny/Housekeeper Elderly Care Please select a service Provider Level * Final prices determined after consultation. Learn more Class A$25–$30/hrPremium experience Class B$23+/hrExperienced Class C$20+/hrEntry level Please select a provider level English Proficiency Level * 0%50%100% 50% Live-in or Live-out? * Live-in Live-out Please select live-in or live-out Currently with another agency? * Yes No Please answer this question Back Continue ScheduleWhen do you need your provider? Start Date * Please select a start date Working Days * Mon Tue Wed Thu Fri Sat Sun Please select at least one working day Working Hours - Start * Select time... 12:00 AM12:30 AM 1:00 AM1:30 AM 2:00 AM2:30 AM 3:00 AM3:30 AM 4:00 AM4:30 AM 5:00 AM5:30 AM 6:00 AM6:30 AM 7:00 AM7:30 AM 8:00 AM8:30 AM 9:00 AM9:30 AM 10:00 AM10:30 AM 11:00 AM11:30 AM 12:00 PM12:30 PM 1:00 PM1:30 PM 2:00 PM2:30 PM 3:00 PM3:30 PM 4:00 PM4:30 PM 5:00 PM5:30 PM 6:00 PM6:30 PM 7:00 PM7:30 PM 8:00 PM8:30 PM 9:00 PM9:30 PM 10:00 PM10:30 PM 11:00 PM11:30 PM Please select start time Working Hours - End * Select time... 12:00 AM12:30 AM 1:00 AM1:30 AM 2:00 AM2:30 AM 3:00 AM3:30 AM 4:00 AM4:30 AM 5:00 AM5:30 AM 6:00 AM6:30 AM 7:00 AM7:30 AM 8:00 AM8:30 AM 9:00 AM9:30 AM 10:00 AM10:30 AM 11:00 AM11:30 AM 12:00 PM12:30 PM 1:00 PM1:30 PM 2:00 PM2:30 PM 3:00 PM3:30 PM 4:00 PM4:30 PM 5:00 PM5:30 PM 6:00 PM6:30 PM 7:00 PM7:30 PM 8:00 PM8:30 PM 9:00 PM9:30 PM 10:00 PM10:30 PM 11:00 PM11:30 PM Please select end time Schedule Notes Back Continue Household InformationTell us about your home Number of Bedrooms * Select... 123 456+ Number of Children * Select... 012 345+ Children's Names and Ages Do you have pets? * Yes No How many pets? How many cats? Is there a pool? * Yes No Provider must swim? Yes No Maybe Elderly Care Details Companion Gender Preference Female Male No preference Back Continue Provider RequirementsFinal details about what you need Cooking Required? * Yes No Maybe What foods should they cook? Ironing Required? * Yes No Maybe Driving Required? * Yes No Do you provide a car? * Yes No Travel Required? * Yes No Maybe How often will they be traveling? Errands Housekeeping Duties Is a schedule provided? * Yes No Qualities you're looking for Back Submit Request Request Submitted! Thank you for choosing Southwest Domestics. Our team will review your request and contact you shortly. Return to Website
