Client Interest Form

Client Interest Form

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

First NameLast Name
YesNo
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
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 an appointment time for the on-site Home Assessment.*
Responsible PartySureHarvest RepresentativeClient
I acknowledge all submitted information is accurate to the best of my knowledge.*

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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.*

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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