Client Information

     
   Client Name:
 

Age:

 

Contact Name:

 

Contact Relationship:

 

Contact Phone:

 

Contact Email:

 

Mailing Address (Optional):

 

City/State/Zip:

   

  
Mental Condition:

 

Confusion?

Yes No  
 

Memory Problems?

Yes No  
 

Ability to Follow Directions?

Poor Fair Good
 

Diagnosed with Dementia/Alzheimer?

Yes No  
    When: 
     

   Physical Health:
 

General Condition?

Poor Fair Good  
 

Ambulatory?

Yes No Wheel- Chair  
 

History of any Major Medical Condition?

Yes No    
 

Please Explain:

When: 
   
     
   Social Factors:
 

Enjoys Socialization?

Yes    No    
 

Ability to Drive?

Yes No    
 

Pets?

Yes No    
 

Smokes?

Yes No    
 

Hobbies / Interests:

       

     
   Assistance Needed:
 

Medication

     
 

Grooming

     
 

Shower/Bathing

     
 

Toileting

     
 

Escort

     
 

Other

     
 

Comments?

     

     
   Preferred  Services:
 

Skilled Nursing

     
 

Assisted Living

     
 

Alzheimer Care

     
 

Board and Care Home

     
 

In Home Care

     
 

Independent Living

     
 

Comments:

     

     
   Monthly Rate (Housing & Care):
 

     
         
 

Comments:

     

         
   Preferred  Location and Type of Housing:

Within 15 miles of

   
 

Studio Apt.

     
 

One Bedroom

     
 

Two Bedroom

     
         
   Time Frame & Best Way to Reach You!

 


 

 

 

 

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