Family Intake Form - Bhutanese Care USA

Application Form

Family Intake Form

Primary Parent or Guardian Name* 1

Secondary Parent or Guardian Name (if applicable)

Primary Phone Number

Secondary Phone Number (optional)

Email Address*

All information is kept strictly confidential and used solely for service matching and placement purposes.

Street Address

City

State

Zip Code

Please check all that apply

Services Interested

Full-time nanny Part-time nanny Newborn Care Specialist Weekend nanny Date-night nanny Housekeeper

Select the rate you are comfortable offering for this position

Hourly Rate

$25–$30 $30–$35 $35–$40 $40–$45 $50+

If requesting a Newborn Care Specialist.

It’s best to begin the search as soon as possible—ideally right after conception or around 3 months into pregnancy.

Due Date

If requesting a Nanny:

Please tell us more about your child(ren)—their age(s), personality, allergies, interests, and anything else you’d love us to know.

Message About Nanny

If requesting a Housekeeper

Please describe the duties, size of home, and traveling needs (if any). The more details you provide, the better we can match the right candidate.

Message House keeper

AdAditional services

Part-Time Overnight weekend kids closet organizing Family Photography

Anything else you’d like us to know or discuss on a call?

Additional Information