New Client Application Form
Name and Email Address of Person Completing Form
*
First Name
Last Name
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Client
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Client
Power of Attorney
You may upload a copy of the Power of Attorney Here or Email or Fax to the office.
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Client Demographics:
Please list all information below for the service recipient.
Client Full Name
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First Name
Last Name
Client Service Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client Social Security Number
*
No Dashes
Date of Birth
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-
Month
-
Day
Year
Date
Client Marital Status
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Please Select
Married
Widowed
Never Married
Domestic Partner
Divorced
Sex
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Please Select
Male
Female
Client Phone Number
*
Format: (000) 000-0000.
Phone Type
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Landline
Cell
Past Profession
*
Favorite Color
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Interests/Hobbies
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Favorite Foods
*
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Service Preferences
How did you hear about us?
*
Please Select
Newspaper
Internet
Friend
Health Provider
Other
Please Specify
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Requested Number of Days Per Week
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Please Select
1
2
3
4
5
6
7
Requested Number of Hours Per Day
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Please Select
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
What date would you like to start services?
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-
Month
-
Day
Year
Date
Are you okay with having some gaps in your requested hours to start quicker and build to your full schedule?
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Yes
No
Anticipated Duration of Services
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2 weeks or less
4-6 weeks
I anticipate a long-term need for in-home care for more than six weeks
What are your main goals for having in home care?
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Please list as much detail about shift day & time preferences as possible. This information will be used to generate your client service agreement.
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Home Assessment
Client Lives:
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Please Select
Alone
With Family
With Spouse
In Nursing Facility
In Assisted Living
Is there smoking in the home?
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Yes
No
Are there pets in the home?
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Yes
No
If Yes, please list type and number of animals.
Have any of the animals ever been aggressive?
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Yes
No
Does the home have central heat and air?
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Yes
No
Does the home have smoke detectors?
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Yes
No
Does the home have carbon monoxide detectors?
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Yes
No
Does the home have any infestation issues?
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Yes
No
Does the home have any other safety hazards we need to be aware of
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Yes
No
If so, please explain:
Does the client have any of the following assistive equipment in the home?
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Roll in shower
Shower Seat
Grab Bars
Wheelchair
Walker
Hospital Bed
Lift Chair
Hoyer Lift
Life Alert
Baby Monitor
Bed Alarm
Bedside Commode
Urinal
Bedpan
Sliding Board
Wheelchair Ramp
Elevator
Standing Lift
Gait Belt
None of these
Other
If other, please describe
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Client Health Assessment
Walking Ability
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Please Select
Walks Independently
Walks with Walker
Walks with Can
Pivot Transfers to Wheelchair Only
Bedbound
Check Any That Appy
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Poor Balance
Fall Risk
Vision Issues
Hearing Issues
Hearing Aids
Glasses Always
Reading Glasses Only
Blind
Deaf
Swallowing Issues
Feeding Tube
Catheter
Special Diet
Blood Thinners
Current Tobacco Use
Current Alcohol Use
On Oxygen
Communicable Disease
Limited Use of Hands
Limited Use of Arms
Poor appetite
Currently Enrolled In Hospice
Currently Enrolled in Home Health
Amputation
Communication Issues
Wandering
Misplacing Items
Leaving on Stove
Verbal Agression
Physical Aggression
Other
If other, please describe
Please List any Known Allergies (foods, medication, latex, etc)
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Please list any current or past health conditions including memory issues with as much detail as possible.
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Current Height
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Current Weight
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Does client have a DNR (Do Not Resuscitate) order ?
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Yes
No
Can Client be left alone?
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Yes
No
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Care Plan
Please list the services that you would like the caregiver to provide.
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Vacuum Floors
Sweep Floors
Mop Floors
Hand Wash Dishes
Wash Dishes with Dishwasher
Put Dishes Away
Empty Trash to exterior trash can
Pull exterior trash can to the road
Dust
Straighten Up Clutter
Wash Laundry
Dry Laundry
Fold Laundry
Hand Laundry
Iron Laundry
Put Away Laundry
Make Beds
Change Bedding/Linens
Shopping without client
Take Client to Shop
Take Client on other errands
Run Errands Without Client in Vehicle
Other Client Transportation
Medication Reminders
Clean Bathrooms
Assistance With Bathing
Assistance With Dressing
Assistance With Socks/Shoes
Assistance with Dentures
Assistance With Brushing Teeth
Assistance with Feeding
Meal Preparation
Assistance with Exercise
Transfers
Repositioning
File Fingernails
Toileting
Custodial Care Due to Cognitive Deficit
Companionship/Other
Feed and Water Pets
Check Mail
Other
If "other" please list here.
If the caregiver provides transportation or errands, should they use the client's car, the caregiver's car?
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Client Car (no additional charge)
Caregiver Car ($0.75/mile)
No Transportation or Errands Should Occur
What do you envision the first 30 minutes of each shift to entail?
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Please Select
Allot time for companionship/conversation
Get Straight to Work on the task list
Spend a few Minutes Checking in with the client to see if any tasks should be modified for the day.
Is there a certain order you would like the tasks completed?
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Yes
No
If yes, please list/explain.
If a new caregiver comes to the home, would you like the care manager to train them, or do you want to train them?
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Care Manager
Client/Family Caregiver
Is there anything else we need to know to help make the shifts successful?
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Are there any areas/items that you would like the caregivers to leave alone?
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What are the top priorities each shift?
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Contacts/Billing Information
Billing Contact:
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First Name
Last Name
Billing Email
*
example@example.com
Billing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Care Physician
*
First Name
Last Name
Primary Care Physician Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Hospice Name (if applicable)
Hospice Company Phone (if applicable)
Please enter a valid phone number.
Format: (000) 000-0000.
Home Health Name (if applicable)
Home Health Phone (if applicable)
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Email
*
example@example.com
Emergency Contact Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please list any other contact in which we have permission to discuss the client and their phone number.
*
Please list anyone (including client or POA) who has permission to access client's online Family Portal With their Email
*
Will client be using long term care insurance to get reimbursed for care? If so, please list Company, and Policy/Claim number if available.
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Client or Power of Attorney Signature
*
Submit
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