Pre-Consultation Questionnaire

Pre-Consultation Questionnaire
Client Information

First NameLast Name
Age
Gender
Primary Contact Name (leave blank if you are the client)

First NameLast Name
Relationship to Client
Primary Contact Email Address
example@example.com
Primary Contact Phone Number
Please enter a valid phone number.
Preferred Method of Contact

E-mailPhone Call
Current Living Situation
Where is the client currently living?
Preferred number of bedrooms
Room Privacy Preference
What is your ideal timeline for moving?
Do you need help selling your current home?

YesNo
Preferred location(s):
What are the client's hobbies or interests?
Care Needs
Please check all that apply

NoneExperiencing weight lossAssistance transferring from bedRequires mobility assistanceMedical equipment requiredAssistance transferring from chairMeal preparation assistanceSpecial dietFeeding supportHygiene supportBladder control issuesDressing supportBowel control issuesToileting supportIncontinence undergarmentsHearing issuesVision issuesOther
Client's pertinent medical history:
Any additional notes or information you'd like us to know:
Should be Empty:

Current Living Situation