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Request a Carer (For Care Companies)

🟦 SECTION 1: Company Details

  • Text Input → Company Name (required)
  • Text Input → Contact Person (required)
  • Text Input → Job Title
  • Email Input → Email Address (required)
  • Phone Input → Phone Number (required)
  • Text Input → Company Registration Number

🟦 SECTION 2: Care Requirement

  • Dropdown → Type of Care Needed
    (Live-in / Domiciliary / Night Care / Respite / Hospital Discharge / Other)
  • Radio Buttons → Start Date
    (Immediate / 1 week / 2–4 weeks / Flexible)
  • Radio Buttons → Duration
    (Ad-hoc / Short-term / Ongoing / Not sure)

🟦 SECTION 3: Client Details

  • Text Area → Care Needs Description (required)
  • Dropdown → Dependency Level
    (Low / Medium / High)
  • Multi-select checkboxes:
    • Dementia
    • Mobility issues
    • Stroke
    • Complex care
    • Other
  • Text Area → Specialist Skills Required

🟦 SECTION 4: Carer Preferences

  • Radio → Gender Preference (Male / Female / No preference)
  • Text Input → Language Requirements
  • Radio → Driving Licence Required (Yes / No)
  • Radio → DBS Required (Yes / Enhanced / No)
  • Radio → Share Code Required (Yes / No)
  • Radio → Smoking Preference

🟦 SECTION 5: Location & Logistics

  • Text Input → Postcode (required)
  • Radio → Accommodation Provided (Yes / No / Partial)
  • Radio → Travel Expenses (Yes / No / To be discussed)

🟦 SECTION 6: Additional Info

  • Text Area → Situation Overview
  • Text Area → Urgent Notes / Risks
  • Radio → Existing Rota (Yes / No)
  • Text Input → Current Care Manager (optional)

🟩 CONSENT SECTION

  • Checkbox (required):
    “I confirm the information provided is accurate and I agree to be contacted regarding suitable carers.”

🟨 SUBMIT BUTTON

👉 Request Carer

💻

Contact Details

  • Company Name (required)
  • Contact Name (required)
  • Email (required)
  • Phone (required)

2. Care Requirement

  • Type of Care (dropdown)
    • Live-in
    • Domiciliary
    • Night Care
    • Respite
    • Hospital Discharge
    • Other
  • Urgency (radio buttons)
    • Immediate (today / urgent)
    • Within 48 hours
    • This week
    • Flexible

3. Client Summary

  • Care needs (short text box) (required)
    (Example placeholder: dementia support, mobility assistance, post-hospital care)
  • Location / Postcode (required)

4. Key Preferences (optional but useful)

  • Driving licence required? (Yes / No / Preferable)
  • DBS required? (Yes / Enhanced / No)
  • Live-in / live-out preference (Live-in / Live-out / Either)

5. Submission

  • Checkbox:
    “I confirm the information provided is accurate and I agree to be contacted.”
  • Button:
    👉 Request a Carer

🚀 WHY THIS VERSION CONVERTS BETTER

  • Cuts from ~20+ fields → ~8 essential fields
  • Reduces decision fatigue
  • Mobile-friendly (fast fill under 60 seconds)
  • Still captures all critical matching data
  • Pushes urgency (important for care placements)

⚙️ OPTIONAL UPGRADE (RECOMMENDED)

If you want to increase conversion even more, add this above the form:

🔴 “Urgent Placement?”

Toggle:

  • Yes → shows only phone + postcode + care type (ultra-fast 20-second form)
  • No → full quick form