Client Interest Form

Client Interest Form

Where compassionate care is nurtured and grown!
Responsible Party Information
Name of Responsible Party

First NameLast Name
Emergency Contact?
Emergency Contacts
Responsible Party's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Responsible Party's Email
example@example.com
Responsible Party's Relationship to Client
Responsible Party's Home Address

Street Address

Street Address Line 2

CityState

Zip Code

Hours + Start/End Times of Care

Total Hours Per Week
Preferred Payment Method:
Please select your minimum budget for weekly services:
Please select an appointment time for the on-site Home Assessment.
Please select the title of the person who filled out this form:
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 NameLast Name
Client Name

First NameLast Name
SureHarvest Home Health Care Representative

First NameLast Name
Date Signed

MonthDayYear
Date
Should be Empty:

Rows	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)

Responsible Party Information

Rows	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