Initial Homecare Questionnaire - Hashtag Together Care Group
Hashtag Together Care Group | HTcaregroup.com | Email: Sarah@HTcaregroup.com
Client and Caregiver Information
First Name of Person Served
*
Last Name of Person Served
*
Primary Caregiver Full Name
*
First Name
Middle Name
Last Name
Primary Caregiver Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Caregiver Email
*
example@example.com
Care Schedule and Service Overview
Care Needed - Monday Hours
Care Needed - Tuesday Hours
Care Needed - Wednesday Hours
Care Needed - Thursday Hours
Care Needed - Friday Hours
Care Needed - Saturday Hours
Care Needed - Sunday Hours
Will the person served be receiving services for the full year?
Yes
No
If No, need caregiving or lifestyle support services while primary caregiver is on travel?
Yes
No
Expectations from caregiving and lifestyle support services
Duration of Care
Homecare History and Preferences
Past in-home care services at another licensed agency
Yes
No
Homecare Preferences
Preferred method of communication for the person served
Do you have questions or concerns about our caregivers?
No
Yes
Questions or concerns about caregivers
Interests of the person served
Personality description of the person served
What gets the person served excited at home?
Health, Dietary, and Behavioral Details
Does the person served have dietary preferences or restrictions?
*
Yes
No
Dietary preferences or restrictions
Does the person served have any allergies or take any medications regularly?
*
Yes
No
Allergies and medications
Does the person served have any unique learning needs?
*
Yes
No
Learning needs
Is the person served up-to-date on all their shots?
*
Yes
No
Not sure
Willing to provide proof of immunization history and most recent annual well care summary
*
Immunization history
Most recent annual well care summary
Does the person served have any behavioral issues?
*
Yes
No
Behavioral issues we should be aware of
Emergency Contacts and Safety
Emergency Contact 1 - Name
*
Emergency Contact 1 - Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact 1 - Email Address
example@example.com
Emergency Contact 2 - Name
Emergency Contact 2 - Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact 2 - Email Address
example@example.com
Is there anyone who should not be allowed near the home of the person served?
Yes
No
Name of person who should not be allowed near the home
Description or identifying marks of person who should not be allowed near the home
Are there family safety concerns we should be aware of?
Yes
No
Family safety concerns
Policies, Payment, and Signature
Have you read our payment policy?
*
Yes
How will the weekly in-home care service fees be paid?
*
Payment Type
*
Check
Bank transfer
Money order
Other
If Other, describe payment type
How would you prefer we contact you in case of an emergency?
*
How would you prefer to receive regular communications from Hashtag Together Care Group?
Have you read our sick policy?
*
Yes
Are you willing to comply with everything listed in our sick policy?
*
Yes
Primary caregiver or person completing the questionnaire - PRINT FULL NAME
*
Primary caregiver or person completing the questionnaire - SIGNATURE
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: