Person who will need a caregiver:

Client’s First Name:

Client’s Last Name:

Phone:

Cell Phone:

Phone Type : IphoneAndroidOthers

Home Address:

City:

State:

Zip Code:

Email Address:

How did you find out about us?
Referred from a friendReferred from a facilitySaw our StorefrontReferred by a One AgencyReferred by another AgencyFound us on the Internet

Referral Name:

1st Family Contact:

First Name:

Last Name:

Relationship:

Home Address:

City:

State:

Zip Code:

Phone:

Cell Phone:

Phone Type : IphoneAndroidOthers

Email Address:

2nd Family Contact:

First Name:

Last Name:

Relationship:

Home Address:

City:

State:

Zip Code:

Phone:

Cell Phone:

Phone Type : IphoneAndroidOthers

Email Address:

Does the patient have a long term insurance policy? YesNo

If Yes:

Insurance Company:

Phone:

Policy and/or Claim Number:

Schedule

Is the Client currently in a facility: YesNo

If yes what is the name of the facility?:

If no what was the last facility that the client was in?:

Start Date:

Discharge Date:

Live In: YesNo

Live Out:YesNo

Live In Fill In:YesNo

Full Time Hourly:YesNo

Part Time Hourly:YesNo

Hospice: YesNo

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)

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Preferred One Agency’s Gender :
FemaleMaleAny

Do you need a One Agency with Driver’s License (to drive the patient to Doctor’s Appointment or grocery shopping ) YesNo

If yes, Client's CarOne Agency'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? YesNo

Is there a separate bedroom? YesNo

If No, what are the sleeping arrangements?

Other:

Is there a TV in the caregiver’s room? YesNo

Is there Wi-Fi in the house? YesNo

Is there a baby monitor so the caregiver can monitor the client at night? YesNo

Are there pets in the home? YesNo

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

Notes and Special Instructions:

Client Information

Age:

Weight:

Gender:
MaleFemale

Height:

Presenting Diagnosis:

Does the client lives alone?:YesNo

Household members living with the client?:

Can the client walk? :with assistanceor without assistance

Can the client stand? on her/his ownor with assistance

Using a walkerUsing a caneUsing a wheelchairBedridden

Is lifting Required? YesNo

If yes, how much:

Can the client push with their legs? YesNo

What % pushing to pulling?:

Is the client:ContinentIncontinent

Does the client have: CatheterColostomyDiapersDiapers just in caseBed padsBedside commode

No

If the client uses diapers, is there a special receptacle for soiled diapers? YesNo

Primary Physician :

Secondary Physician :

Special Dietary Needs:YesNo

If yes, please list:

Cognitive Ability:AlertOriented

Dementia / Alzheimer’s:BeginningModerateAdvancedSundowners(patient is more disoriented at night)

Is the client sleeping at night?YesNo

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

Does the client need assistance with ADL’s: YesNo
(needs small meals, light housekeeping, and laundry)

Personal hygiene/bathing(a shower stool with a hose attachment):YesNo

Meals prepared:YesNo

Laundry (fluff and fold):YesNo

Has the patient ever been placed under a 5150? YesNo

Does the patient have a history of strike out? YesNo

Is the patient smoking? YesNo

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

Clients Pre-Requisites for Caregivers:

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? YesNo

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

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.