assessment

Our goal is to be able to provide quality and customized care to meet our Clients needs and expectations.

Our Caregivers are trained to understand the concept of individuality of all persons, their experiences, rights, interests and needs.
They are also trained to adapt to various settings while always keeping the comfort, safety and security of their Clients in mind.

Our Caregivers will provide optimal support to assist Clients to do what they wish to do without inhibiting them.

Assistance with personal hygiene will be provided with sensitivity and respect for our Client's dignity and privacy.

To help us better serve you, please complete the following:
(Items marked with * are required)

Contact Information

Please enter your information below:

*Name:

Address:

Apt #/Unit:

*City:

Province:

Postal Code:

*Contact Email:

Phone#:

Day:

Evening:

I am interested in in-home care for:

The level of care needed is:

Location where Care is needed:

Care is needed:

Our Client care needs are important. Having some assistance allows our Clients to maintain independence as well as vitality and joy of living. Please help us identify and assess the needs and capabilities of our Clients requiring our Care.

Mobility of Client receiving care:

Personal Care Needs: (please check all that apply)

Do not have personal care needs at this time

Getting in and out of bathtub/washing hair/brushing hair/cleaning teeth/shaving etc.

Using the commode and/or incontinence management products

Not known

Homemaking Needs: (please check all that apply)

Able to do household chores

Assistance cleaning/dusting

Assistance with laundry/ironing/changing linens

Assistance with pet/plant care

Assistance with garbage take-out/lawn mowing/snow shoveling

Other, please specify:

Nutritional Needs: (please check all that apply)

Able to shop and prepare own meals

Assistance with planning and shopping for meals

Assistance in preparing and cooking meals

Assistance eating meals

Not known

Companionship/Respite Care Needs: (please check all that apply)

Assistance with transportation and errand services

Company to go on appointments, trips and or events

Overnight companionship

Companionship when primary caregiver is absent

Not known

Medication Assistance/Reminders: (please check all that apply)

Able to take medication on own

Reminders on when to take medication

Assistance in taking medication

Not known

Home safety environment: (please check all that apply)

Able to safely live in current residence independently

Occasional assistance with maintaining a safe, comfortable environment

Assistance at home with maintenance and safety

Not known

Health Conditions: (please check all that apply)

Alzheimer or dementia	Arthritis	Brain Injury
Cancer	Diabetes	Heart Disease
Lung Problem	Open Wounds	Pain
Parkinson’s Disease	Recovering from surgery	Stroke
Other	Not known

Is there anything else you feel we should know?:

Thank you for taking the time to allow us to serve you better. A member of our staff will be in contact with you shortly.

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