AGC Plan of Care

PLAN OF CARE
MonthDayYear
Date
Client’s Name*

First NameLast Name
Requested Days, Times, and Duration of Companion Care Services*
Home Management Tasks Requested:

ShoppingMeal PreparationMeal PlanningEntertainingVisiting Family or FriendsTransportation/AGC Vehicle @.70/mileTransportation/Client Vehicle (free)Companionship/SocializingMedication RemindersRespite CareOutings & AppointmentsLight HousekeepingLaundryLinensOrganize Mail & CorrespondencePlant CarePet CareOther:
Personal Care:

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

Hard of HearingHearing AidsDeafDenturesWears GlassesBlind
Assistive Devices:

CaneWalkerWheelchairOther:
Mental State:

AlertOrientedForgetfulConfusedEasily AgitatedLethargic
Communication Skills:

BrailleSign LanguagePrimary Language (if not English):
Activities you are able to complete independently:

Dress SelfBathe SelfBrush TeethComb HairFeed SelfTake Medications
Medical Problems (if applicable):
Allergies (food etc):
I have a DNR (Do Not Resuscitate):*

YesNo
Do you have any pets?
Caregiver Preferences

Prefer Male CaregiverPrefer Female CaregiverOK with Female or Male
Additional Comments / Notes:
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:*

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Client's Name*

First NameLast Name
ALWAYS GOOD COMPANY REPRESENTATIVE:
Prepared By:
AGC Representative's Name

First NameLast Name
Credentials/Title
Should be Empty:

Additional Comments / Notes:

ALWAYS GOOD COMPANY REPRESENTATIVE: