Person who will need a caregiver:

Client's First Name:
Client's Last Name:
Cell Phone: Text OK
Phone Type : Iphone Android Others
Home Address:
City: State: Zip Code:
Email Address:

How did you find out about us?
Referral Name:

1st Family Contact:
First Name:
Last Name:
Home Address:
City: State: Zip Code:
Cell:Text OK
Phone Type : Iphone Android Others
Email Address:

2nd Family Contact:
First Name:
Last Name:
Home Address:
City: State: Zip Code:
Cell:Text OK
Phone Type: Iphone Android Others
Email Address:

Does the patient have a long term insurance policy?
Yes No

If Yes:
Insurance Company:

Policy and/or Claim Number:

Date of Birth:


Start Date:
Discharge Date:

Live In:Yes No

Live Out:Yes No

Live In Fill In:Yes No

Full Time Hourly:Yes No

Part Time Hourly:Yes No

Hospice:Yes No

We need live in 7 Days


We need live in for these days only Change over time is usually around dinner time.

For Live Out(Total Hours):

Total Hours Preferred Time

Preferred Caregiver's Gender :

Do you need a caregiver with Driver's License (to drive the patient to Doctor's Appointment or grocery shopping ) Yes No

If yes, Client's CarCaregiver's Car

Please Note:
Most hourly caregivers drive, live in caregivers generally do not drive although they typically have someone drop them off and pick them up and can usually handle the grocery shopping for the client. Live in caregivers who drive are rare and in demand, they usually request an extra $20 per day because they are a live in driver.

Also, most caregivers are requesting $1 Per Mile for mileage if they are driving their own vehicle.

For Live In:

Do you have a bedroom for caregiver? Yes No

Is there a separate bedroom?Yes No

If No, what are the sleeping arrangements?


Is there a TV in the caregiver's room?Yes No

Is there Wi-Fi in the house?Yes No

Is there a baby monitor so the caregiver can monitor the client at night?Yes No

Are there pets in the home?Yes No

If yes, please describe all(size also), and what responsibilities you would expect from the caregiver:

Notes and Special Instructions:






Presenting Diagnosis:

Does the client lives alone? Yes No:

Household members living with the client?:

Can the client walk? with assistance or without assistance:

Can the client stand? on her/his own or with assistance:

Using a walker
Using a cane
Using a wheelchair Bedridden

Is lifting Required? Yes No

If yes, how much:
Can the client push with their legs?Yes No

What % pushing to pulling?:

Is the client:Continent Incontinent

Does the client have:Catheter Colostomy
Diapers Diapers just in case
Bed pads Bedside commode


If the client uses diapers, is there a special receptacle for soiled diapers? Yes No

Primary Physician :

Secondary Physician :

Special Dietary Needs:Yes No
If yes, please list:

Cognitive Ability:Alert Oriented

Dementia / Alzheimer's:Beginning Moderate
Advanced Sundowners(patient is more disoriented at night)

Is the client sleeping at night?Yes No

How many times does the client use the bathroom between 10pm-6am?

Does the client need assistance with ADL's:
Yes No

(needs small meals, light housekeeping, and laundry)

Personal hygiene/bathing(a shower stool with a hose attachment):Yes No

Meals prepared:Yes No

Laundry (fluff and fold):Yes No

Has the patient ever been placed under a 5150? Yes No

Does the patient have a history of strike out? Yes No

Is the patient smoking? Yes No

If yes, the client is smoking and/or using: Cigar Vape


Yes I would like to use your debit card.   We will contact you to set up Debit Billing.

If you are choosing direct pay, would you like an invoice that reflects the total expense?
Yes No

Invoices are generated on a weekly basis. Would you prefer?
E-bill Snail Mail

Billing Information:

Billing Address
City: State: Zip Code:

Most clients write checks, but if you prefer to create a re-occuring transaction.
We accept Debit Card.