

	Customer Service: (626) 417-7059

24 Hours a Day, 7 Days a Week
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Client number

Clients Name

First Name

Last Name

Phone Number

Address

Address Line 1
Address Line 2
City	State	Zip

How did you find out about us?

Referral Name:

1st Family Contact:

Name

First Name

Last Name

Relationship

Address

Address Line 1
Address Line 2
City	State	Zip

Phone Number

2nd Family Contact:

Name

First Name

Last Name

Relationship

Address

Address Line 1
Address Line 2
City	State	Zip

Phone Number

Schedule

Start Date:

Discharge Date:

Live In

Yes

Live Out:

Yes

Live In Fill In:

Yes

Full Time Hourly:

Yes

Part Time Hourly:

Yes

Hospice:

Yes

We need live in 7 Days

Yes

Do you need a caregiver with Driver's License (to drive the patient to Doctor's Appointment or grocery shopping )

Yes

If Yes,

Clients Car

Caregiver's Car

Please Note:
Most hourly caregivers drive, live in caregivers generally do not drive although they typically have someone drop them off and pick them up and can usually handle the grocery shopping for the client. Live in caregivers who drive are rare and in demand, they usually request an extra $20 per day because they are a live in driver.

Also, most caregivers are requesting $1 Per Mile for mileage if they are driving their own vehicle.

For Live In:

Do you have a bedroom for caregiver?

Yes

Is there a separate bedroom?

Yes

If No, what are the sleeping arrangements?

Is there a TV in the caregiver's room?

Yes

Is there Wi-Fi in the house?

Yes

Is there a baby monitor so the caregiver can monitor the client at night?

Yes

Are there pets in the home?

Yes

If yes, please describe all(size also), and what responsibilities you would expect from the caregiver:

Notes and Special Instructions:

Clients Information

Age

Weight:

Height:

Presenting Diagnosis:

Does the client lives alone?

Yes

Household members living with the client?:

Can the client walk?

with assistance

or without assistance:

Can the client stand?

on her/his own

or with assistance

using a walker

using a cane

using a wheelchair

bedridden

Is lifting Required?

Yes

If yes, how much:

Can the client push with their legs?

Yes

What % pushing to pulling?:

Is the client:

Continent

InContinent

If the client uses diapers, is there a special receptacle for soiled diapers?

Yes

Medications:

Yes

If yes, please list:

Special Dietary Needs:

Yes

If yes, please list:

Is the client sleeping at night?

Yes

How many times does the client use the bathroom between 10pm-6am?

Does the client need assistance with ADL's:

Yes

Personal hygiene/bathing(a shower stool with a hose attachment):

Yes

Meals prepared:

Yes

Laundry (fluff and fold):

Yes

Has the patient ever been placed under a 5150?

Yes

Does the patient have a history of strike out?

Yes

A Caring Place

171 North Altadena Dr. Suite #275
Pasadena
CA
91107

Phone: (626) 417-7059
No refunds for payments or donations.