Client Intake Assessment

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Please check mark the box next to the services you wish to be provided for.

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Please select the boxes you would like a Home care aid for. *

Medication Reminders: Helping clients stay on track with their prescribed medication schedules

Social and Recreational Activities: Encouraging participation in hobbies, outings, or community events to stay active and engaged.

Standby assistance within arm’s reach for safety while performing daily activities

Light Housekeeping: household chores/Laundry

Personal Care: Assistance with dressing, self-feeding, oral hygiene, hair care, grooming, toileting, and bathing

Meal Preparation: Planning and preparing nutritious meals tailored to dietary preferences or restrictions.

Transportation: Providing safe transport to medical appointments, social events, or errands.

Other:

Required

The services listed below are comprehensive home care services that is NOT provided by our home care givers.

 Advanced practice, registered or licensed practical nurse services

 Physical/occupational therapy, speech-language pathologist or respiratory therapy services

 Social worker, dietician or nutritionist services

 Medication management services

 Delegated tasks to unlicensed personnel

 Treatment and therapies

 Providing eating assistance for clients with complicating eating problems

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