Name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Phone

(###)

###

####

Home Address: *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Physical Wellness *

Does the client need help with any of the following? (Check all that apply)

Bathing or Showering

Dressing or Grooming

Toileting or Incontinence care

Walking or Transferring

Meal Preparation or Feeding

Medication Reminders

Does the client use any mobility aids? (e.g., walker, cane, wheelchair)

YES

NO

Cognitive & Emotional Wellness *

Has the client been diagnosed with dementia or memory loss?

YES

NO

Are there moments of confusion, anxiety, or agitation? *

YES

NO

Does the client enjoy structured activities like puzzles, games, or memory prompts? *

YES

NO

Home Environment & Safety *

Are there any safety concerns in the home? (e.g., stairs, loose rugs, poor lighting)

YES

NO

Is there assistive equipment in place? (e.g., grab bars, shower chair) *

YES

NO

Are there specific times when care is most needed? *

Does the client need help with any of the following? (Check all that apply)

YES

NO

Does the client prefer a structured routine or a more flexible day? *

Structured Routine

Flexible Day

Social & Emotional Connection *

Does the client enjoy socializing or prefer quiet, independent time?

Socializing

Quiet Independent Time

Are there any cultural, spiritual, or personal traditions that are important?

YES

Option 2

Household & Lifestyle Support

What kind of help is needed around the home?

Light housekeeping

Laundry

Grocery shopping

Transportation to appointments

Meal planning or cooking

Are there any allegies/ dietary needs or preferences? *

YES

NO

Caregiver Compatibility *

What kind of personality would the client feel most comfortable with?

Calm and gentle

Outgoing and Engaging

Quiet and bOservant

Flexible and Adaptable

Would you like help exploring ways to make care more affordable?

YES

NO