Person who will need a caregiver: Client's First Name: Client's Last Name: Phone: Cell Phone: Text OK Phone Type : Iphone Android Others Home Address: City: State: Zip Code: Email Address: How did you find out about us? Referred from a friend Referred from a facility Saw our Storefront Referred by a Caregiver Referred by another Agency Found us on the Internet Referral Name: 1st Family Contact: First Name: Last Name: Relationship: Home Address: City: State: Zip Code: Phone: Cell: Text OK Phone Type: Iphone Android Others Email Address: 2nd Family Contact: First Name: Last Name: Relationship: Home Address: City: State: Zip Code: Phone: 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: Phone Policy and/or Claim Number: SCHEDULE 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. Sunday Monday Tuesday Wednesday Thursday Friday Saturday For Live Out(Total Hours): Total Hours Preferred Time Sunday -- 1:00 AM 2:00 AM 3:00 AM 4:00 AM 5:00 AM 6:00 AM 7:00 AM 8:00 AM 9:00 AM 10:00 AM 11:00 AM 12:00 PM 1:00 PM 2:00 PM 3:00 PM 4:00 PM 5:00 PM 6:00 PM 7:00 PM 8:00 PM 9:00 PM 10:00 PM 11:00 PM 12:00 PM -- 1:00 AM 2:00 AM 3:00 AM 4:00 AM 5:00 AM 6:00 AM 7:00 AM 8:00 AM 9:00 AM 10:00 AM 11:00 AM 12:00 PM 1:00 PM 2:00 PM 3:00 PM 4:00 PM 5:00 PM 6:00 PM 7:00 PM 8:00 PM 9:00 PM 10:00 PM 11:00 PM 12:00 PM Monday -- 1:00 AM 2:00 AM 3:00 AM 4:00 AM 5:00 AM 6:00 AM 7:00 AM 8:00 AM 9:00 AM 10:00 AM 11:00 AM 12:00 PM 1:00 PM 2:00 PM 3:00 PM 4:00 PM 5:00 PM 6:00 PM 7:00 PM 8:00 PM 9:00 PM 10:00 PM 11:00 PM 12:00 PM -- 1:00 AM 2:00 AM 3:00 AM 4:00 AM 5:00 AM 6:00 AM 7:00 AM 8:00 AM 9:00 AM 10:00 AM 11:00 AM 12:00 PM 1:00 PM 2:00 PM 3:00 PM 4:00 PM 5:00 PM 6:00 PM 7:00 PM 8:00 PM 9:00 PM 10:00 PM 11:00 PM 12:00 PM Tuesday -- 1:00 AM 2:00 AM 3:00 AM 4:00 AM 5:00 AM 6:00 AM 7:00 AM 8:00 AM 9:00 AM 10:00 AM 11:00 AM 12:00 PM 1:00 PM 2:00 PM 3:00 PM 4:00 PM 5:00 PM 6:00 PM 7:00 PM 8:00 PM 9:00 PM 10:00 PM 11:00 PM 12:00 PM -- 1:00 AM 2:00 AM 3:00 AM 4:00 AM 5:00 AM 6:00 AM 7:00 AM 8:00 AM 9:00 AM 10:00 AM 11:00 AM 12:00 PM 1:00 PM 2:00 PM 3:00 PM 4:00 PM 5:00 PM 6:00 PM 7:00 PM 8:00 PM 9:00 PM 10:00 PM 11:00 PM 12:00 PM Wednesday -- 1:00 AM 2:00 AM 3:00 AM 4:00 AM 5:00 AM 6:00 AM 7:00 AM 8:00 AM 9:00 AM 10:00 AM 11:00 AM 12:00 PM 1:00 PM 2:00 PM 3:00 PM 4:00 PM 5:00 PM 6:00 PM 7:00 PM 8:00 PM 9:00 PM 10:00 PM 11:00 PM 12:00 PM -- 1:00 AM 2:00 AM 3:00 AM 4:00 AM 5:00 AM 6:00 AM 7:00 AM 8:00 AM 9:00 AM 10:00 AM 11:00 AM 12:00 PM 1:00 PM 2:00 PM 3:00 PM 4:00 PM 5:00 PM 6:00 PM 7:00 PM 8:00 PM 9:00 PM 10:00 PM 11:00 PM 12:00 PM Thursday -- 1:00 AM 2:00 AM 3:00 AM 4:00 AM 5:00 AM 6:00 AM 7:00 AM 8:00 AM 9:00 AM 10:00 AM 11:00 AM 12:00 PM 1:00 PM 2:00 PM 3:00 PM 4:00 PM 5:00 PM 6:00 PM 7:00 PM 8:00 PM 9:00 PM 10:00 PM 11:00 PM 12:00 PM -- 1:00 AM 2:00 AM 3:00 AM 4:00 AM 5:00 AM 6:00 AM 7:00 AM 8:00 AM 9:00 AM 10:00 AM 11:00 AM 12:00 PM 1:00 PM 2:00 PM 3:00 PM 4:00 PM 5:00 PM 6:00 PM 7:00 PM 8:00 PM 9:00 PM 10:00 PM 11:00 PM 12:00 PM Friday -- 1:00 AM 2:00 AM 3:00 AM 4:00 AM 5:00 AM 6:00 AM 7:00 AM 8:00 AM 9:00 AM 10:00 AM 11:00 AM 12:00 PM 1:00 PM 2:00 PM 3:00 PM 4:00 PM 5:00 PM 6:00 PM 7:00 PM 8:00 PM 9:00 PM 10:00 PM 11:00 PM 12:00 PM -- 1:00 AM 2:00 AM 3:00 AM 4:00 AM 5:00 AM 6:00 AM 7:00 AM 8:00 AM 9:00 AM 10:00 AM 11:00 AM 12:00 PM 1:00 PM 2:00 PM 3:00 PM 4:00 PM 5:00 PM 6:00 PM 7:00 PM 8:00 PM 9:00 PM 10:00 PM 11:00 PM 12:00 PM Saturday \ -- 1:00 AM 2:00 AM 3:00 AM 4:00 AM 5:00 AM 6:00 AM 7:00 AM 8:00 AM 9:00 AM 10:00 AM 11:00 AM 12:00 PM 1:00 PM 2:00 PM 3:00 PM 4:00 PM 5:00 PM 6:00 PM 7:00 PM 8:00 PM 9:00 PM 10:00 PM 11:00 PM 12:00 PM -- 1:00 AM 2:00 AM 3:00 AM 4:00 AM 5:00 AM 6:00 AM 7:00 AM 8:00 AM 9:00 AM 10:00 AM 11:00 AM 12:00 PM 1:00 PM 2:00 PM 3:00 PM 4:00 PM 5:00 PM 6:00 PM 7:00 PM 8:00 PM 9:00 PM 10:00 PM 11:00 PM 12:00 PM Preferred Caregiver's Gender : Female Male Any 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? Other: 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: CLIENT'S INFORMATION Date of Birth: Age: Weight: Gender: Male Female Height: 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 Hoyer Lift Gait Lift None, Caregiver will lift the client 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 No 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 CLIENT'S BILLING 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 Email Address: Billing Information: Insurance Email Address Billing Address City: State: Zip Code: Most clients write checks, but if you prefer to create a re-occuring transaction. We accept Debit Card.