Client Interest Form
Where compassionate care is nurtured and grown!
Responsible Party Information
Name of Responsible Party
*
First Name
Last Name
Emergency Contact?
*
Yes
No
Emergency Contacts
*
Responsible Party's Phone Number
*
Please enter a valid phone number.
Responsible Party's Email
*
example@example.com
Responsible Party's Relationship to Client
*
Responsible Party's Home Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
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Client Information
Today's Date
-
Month
-
Day
Year
Date
Full Name
*
First Name
Last Name
Age
*
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Female
Male
Non-Binary
Transgender
Phone Number (If Different from Responsible Party)
*
Please enter a valid phone number.
Age Group
*
Teen (14-18)
Young Adult (19-30)
Adult (31-59)
Senior Adult (60+)
Primary Language
*
English
Spanish
Other
Service Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Height
Weight
Living Status
*
Independent
With Loved One
Smoker?
*
Yes
No
Insect/Rodent Infestation?
*
Yes
No
Pets?
*
Cat
Dog
Other
Please select all infestations:
*
Bed Bugs
Roaches
Rats/Mice
Flies/Fruit Flies
Fleas
Other
Would you like assistance with scheduling pest control?
Yes
No
Personality Traits
*
Adventurous/Outgoing
Aggressive/Angry/Rude
Confusion/Delusional
Happy/Easy-Going
Introvert
Impulsive
Paranoid
Sad/Depressed
Other
Likes
*
Dislikes
*
Enjoyment Activities
*
Games
Indoor
Outdoor
Puzzles
None
Other
Diagnosis or Conditions
*
Allergies
ALS
Ambulation (Post-Surgical) Exercise
Aneurysms
Anxiety
Arthritis
Asthma
Blindness
Bowel/Bladder Incontinence
Brain Surgeries
Cancer
Car Accidents
Catheter Care
Chronic Kidney Disease
Congestive Heart Failure
COPD
Deafness
Dementia
Depression
Diabetes
Dialysis
Eating Disorder
Falling
Heart Disease
High Blood Pressure
High Cholesterol
Hospice
Hospital-Acquired Pneumonia
Hypertension
Late Stages of Cancer
Legally Blind
Monitor Vital Signs
Multimorbidity
Obesity
Osteoarthritis
Osteoporosis
Paralysis
Parkinson's Disease
Respiratory
Short Term Memory Loss
Spinal Injuries
Stroke
Tube Feeding
Tube Irrigation
Wound Care
Other
Please select all applicable insurances:
*
Aetna
AmeriHealth
Anthem/Blue Cross Blue Shield
Buckeye
CareSource
Cigna
Humana
Medicaid
Molina
WellCare
United Health Care
Other
Any hospitalizations or surgeries within the last 60 Days?
*
Yes
No
List Recent Hospitalizations or Surgeries
*
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Service Needs
What does the Client need assistance with and how often?
Mobility Status - Equipment
*
Equipment
Transformation Assistance
Cane
Yes
No
Yes
No
Walker
Yes
No
Yes
No
Wheelchair
Yes
No
Yes
No
Rollator
Yes
No
Yes
No
General Duties
*
Sun
Mon
Tues
Wed
Thurs
Fri
Sat
N/A
Bathing
Dressing/Undressing
Feeding
Personal Care (Grooming/Skin Care, Shaving, Oral Hygiene)
Splints/Braces Adjusting
Toileting Assistance
Meals
*
Sun
Mon
Tues
Wed
Thurs
Fri
Sat
N/A
Meal Prep
Meal Serving - Breakfast
Meal Serving - Lunch
Meal Serving - Dinner
Meal Serving - Snacks
Are you interested in having a Private Chef perform a meal prep presentation?
Yes
No
Food preferences (likes/dislikes) and allergies:
*
Light Housekeeping
*
Sun
Mon
Tues
Wed
Thurs
Fri
Sat
N/A
Sweeping/Vacuuming/Mopping
Dusting General Level Areas
Kitchen
Bathroom
Laundry
Changing Linens
Taking Out Trash
Watering Plants (Independent Living Only)
Errands
*
Sun
Mon
Tues
Wed
Thurs
Fri
Sat
N/A
Doctors Appointments
General Requests
Grocery Shopping
Outside Activities
Pharmacy
Post Office
Transportation
*
Sun
Mon
Tues
Wed
Thurs
Fri
Sat
Special Occurrence
N/A
Doctors Appointments
General Requests
Grocery Shopping
Outside Activities
Pharmacy
Post Office
Describe desired outside activities (ex. Special Occurrence, Walking around the park, etc.):
*
Please select any additional interests you may have:
Physical Exercise Sessions
Deep House Cleaning
Happy Harvest Respite Package - may include music, dance, or art classes led by trained providers that often offer group meals, entertainment, or just time to socialize with others.
Please select the type of meal plan you are interested in:
Heart Healthy Harvest - Focus on healthy cardiac function or various heart diseases.
Pure Health Harvest - High-Alkaline/PH balance diets for inflammation, gout and arthritis.
Sure Earth Harvest - Mediterranean-Style Diet (protein, nuts, fresh fruits) focused on diabetics.
Do you have any additional comments or concerns?
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Client Preferences
Hours + Start/End Times of Care
*
Start Time:
AM/PM
End Time:
AM/PM
Total Hours (30 Mins = .5)
Sunday
12:00
12:30
1:00
1:30
2:00
2:30
3:00
3:30
4:00
4:30
5:00
5:30
6:00
6:30
7:00
7:30
8:00
8:30
9:00
9:30
10:00
10:30
11:00
11:30
AM
PM
12:00
12:30
1:00
1:30
2:00
2:30
3:00
3:30
4:00
4:30
5:00
5:30
6:00
6:30
7:00
7:30
8:00
8:30
9:00
9:30
10:00
10:30
11:00
11:30
AM
PM
Monday
12:00
12:30
1:00
1:30
2:00
2:30
3:00
3:30
4:00
4:30
5:00
5:30
6:00
6:30
7:00
7:30
8:00
8:30
9:00
9:30
10:00
10:30
11:00
11:30
AM
PM
12:00
12:30
1:00
1:30
2:00
2:30
3:00
3:30
4:00
4:30
5:00
5:30
6:00
6:30
7:00
7:30
8:00
8:30
9:00
9:30
10:00
10:30
11:00
11:30
AM
PM
Tuesday
12:00
12:30
1:00
1:30
2:00
2:30
3:00
3:30
4:00
4:30
5:00
5:30
6:00
6:30
7:00
7:30
8:00
8:30
9:00
9:30
10:00
10:30
11:00
11:30
AM
PM
12:00
12:30
1:00
1:30
2:00
2:30
3:00
3:30
4:00
4:30
5:00
5:30
6:00
6:30
7:00
7:30
8:00
8:30
9:00
9:30
10:00
10:30
11:00
11:30
AM
PM
Wednesday
12:00
12:30
1:00
1:30
2:00
2:30
3:00
3:30
4:00
4:30
5:00
5:30
6:00
6:30
7:00
7:30
8:00
8:30
9:00
9:30
10:00
10:30
11:00
11:30
AM
PM
12:00
12:30
1:00
1:30
2:00
2:30
3:00
3:30
4:00
4:30
5:00
5:30
6:00
6:30
7:00
7:30
8:00
8:30
9:00
9:30
10:00
10:30
11:00
11:30
AM
PM
Thursday
12:00
12:30
1:00
1:30
2:00
2:30
3:00
3:30
4:00
4:30
5:00
5:30
6:00
6:30
7:00
7:30
8:00
8:30
9:00
9:30
10:00
10:30
11:00
11:30
AM
PM
12:00
12:30
1:00
1:30
2:00
2:30
3:00
3:30
4:00
4:30
5:00
5:30
6:00
6:30
7:00
7:30
8:00
8:30
9:00
9:30
10:00
10:30
11:00
11:30
AM
PM
Friday
12:00
12:30
1:00
1:30
2:00
2:30
3:00
3:30
4:00
4:30
5:00
5:30
6:00
6:30
7:00
7:30
8:00
8:30
9:00
9:30
10:00
10:30
11:00
11:30
AM
PM
12:00
12:30
1:00
1:30
2:00
2:30
3:00
3:30
4:00
4:30
5:00
5:30
6:00
6:30
7:00
7:30
8:00
8:30
9:00
9:30
10:00
10:30
11:00
11:30
AM
PM
Saturday
12:00
12:30
1:00
1:30
2:00
2:30
3:00
3:30
4:00
4:30
5:00
5:30
6:00
6:30
7:00
7:30
8:00
8:30
9:00
9:30
10:00
10:30
11:00
11:30
AM
PM
12:00
12:30
1:00
1:30
2:00
2:30
3:00
3:30
4:00
4:30
5:00
5:30
6:00
6:30
7:00
7:30
8:00
8:30
9:00
9:30
10:00
10:30
11:00
11:30
AM
PM
Total Hours Per Week
Preferred Payment Method:
*
Cash/Money Order (Pay at Office Location)
Digital Check/ACH Transfer (1%)
Debit/Credit Card (2.99%)
Apple Pay (2.99%)
PayPal (2.99%)
Please select your minimum budget for weekly services:
*
Please Select
$100-$300
$300-$500
$500-$1000
$1000+
Please select an appointment time for the on-site Home Assessment.
*
Please select the title of the person who filled out this form:
*
Responsible Party
SureHarvest Representative
Client
I acknowledge all submitted information is accurate to the best of my knowledge.
*
I acknowledge that I have filled out all information on this form to the best of my knowledge based on the individual who verbally provided the information.
*
Responsible Party Name
*
First Name
Last Name
Client Name
*
First Name
Last Name
SureHarvest Home Health Care Representative
*
First Name
Last Name
Date Signed
-
Month
-
Day
Year
Date
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