Form
Heading
Client Preference Assessment Form
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Preferred Name(if any)
date of birth
-
Month
-
Day
Year
Date
Emergency Contact (Name & Number)
Preferred Communication Method
Please Select
Phone
Text
Other
Favorite Meals or snacks
Any Know Food Allergies or Sensitivities
Religious or Cultural Preferences
House Rules (e.g., no shoes inside, doorbell use, etc.):
Do you pets? If yes, Please describe:
Bathing Preferences( Time of day, assistance needed, etc.):
Clothing Preferences (Style, comfort, etc.)
Any Activities You Enjoy (TV, reading, games, walks)
Do you smoke or allow?
Any topics or behavior you consider off-limits?
Preferred Gender of Caregiver (if applicable):
Any other Comments or special instructions:
Submit
Should be Empty: