JHC Pre-Care In-Home Assessment 
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Email *
Name of Caller, Phone Number *
Date *
MM
/
DD
/
YYYY
Name of Person Receiving Care: *
Diagnosis: *
Address:
*
Care Goals (What are you wanting the care to accomplish):
*
Gender, Date of Birth, Height, Weight
*
How did you hear about us? *
Required
Lives With/ Relation
*
How soon will your love one need help?
*
What type of schedule does your loved one have?
*
What Days are you looking for service: (Shift length minimum 4 hrs. per day 12 hrs. week)
*
Required
What times are you looking for service?
 (Shift length minimum 4 hrs. 3 days per week 12 hrs. week) Please give 2 estimated time
*
Method of Payment *
Required
ADL's needing assistance with *
Required
Toileting:  Please select all that applies: *
Ambulation: Please select which ones applies to your loved one
*
Required
Risk that you have notice. Please select all that applies: *
Required
Currently Receiving Services From:
*
Required
Name and contact information for any of the above listed providers
*
Medical Condition *
Required
Are there any pets in the home? What breed? Is the pet in a cage? *
Past Profession? *
Mental Behaviors:
*
Required
History of:
*
Required
Who Manages meds/sups:
*
Assistance with meals:
*
Required
Appetite:
*
Required
Other: *
Required
Please list a few days and times that you would like to schedule for us to come out and conduct an in home assessment? *
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