2024 AGC Plan of Care / Couples

Client’s Name*

First NameLast Name

Requested Days, Times, and Duration of Companion Care Services*

Home Management Tasks Requested:

Personal Care:

Lay out clothesSet up to brush teethSet up for bath or showerStandby for bath or shower

Client Information:

Assistive Devices:

CaneWalkerWheelchairOther:

Mental State:

Communication Skills:

BrailleSign LanguagePrimary Language (if not English):

Activities you are able to complete independently:

Medical Problems (if applicable):

Allergies (food etc):

I have a DNR (Do Not Resuscitate):*

YesNo

Client Goals: Safety and home management needs will be met during service hours as evidenced by neat, clean client and home, and client satisfaction with services.

I have participated in preparing this plan and developing the goals:*

Client Two's Name*

First NameLast Name

Prepared By:

AGC Representative's Name

First NameLast Name

Credentials/Title

PLAN OF CARE: Couples

CLIENT ONE

ADDITIONAL COMMENTS / NOTES:

CLIENT TWO

ADDITIONAL COMMENTS / NOTES:

ALWAYS GOOD COMPANY REPRESENTATIVE: