Plan for Independence & Enrollment Packet

Favorite things

Full Name

Date of birth

Color

Cuisine

Snacks

Sweet treat

Soda/Coffee/Tea/Drink

Flowers

Books/Authors

Music

Hobbies

Restaurants

Baked goods

Place(s) to shop

Candle

YES

Candle Scents

Lotion

YES

Lotion Scents

Anything else we should know

Client Demographic Information

Address

Street Address

City

State

Country

Postal Code

Secondary Address

City

State

Zip Code

Phone Number (Home)

Phone Number (Cell)

Client Preferred Language

Communication needs

Emergency Contact Information

Primary Emergency Contact Name

Relationship to Client

Primary Contact Number

Primary Contact Alternate Phone Number

Secondary Emergency Contact Name

Relationship to Client - Secondary

Secondary Contact Number

Secondary Contact Alternate Phone Number

Primary Healthcare Provider Information

Primary Care Physician Name

Physician Phone Number

Preferred Hospital

Preferred Hospital or Emergency Facility

Hospital Name

Clinic Name

Address (if known)

Plan of Care Preparation for Personal Assistance Services

Evaluator Name & Title

Date of Evaluation

Height

Weight

Gender

Marital Status

Anniversary Date

Social Security Number

Family / Caregiver involved

Yes

Names

Relationship to Client

Health Concerns and Information

Allergies and Symptoms

Dietary Needs & Restrictions

Diagnosed Health Conditions

Medical History

Surgical History

History of Falls

Functional Assessment

Alert / Oriented to

Forgetful / Confused; If so, is it related to a Diagnosis:

Speech

Mental Health

Behavior

Respiratory System

If so how many liters

Trachea

Open

Closed

Related Diagnosis

Eyes, Ears, Nose and Oral care

Oral Care

Musculoskeletal System:

Musculoskeletal System - Gait:

Digital Dexterity

Ambulation / Transfers Assistance

Dressing/Grooming Assistance

Toileting Assistance

Bathing Assistance

Range of Motion

Pain

Skin Assessment: Important note: If a client has any pressure ulcers or any wound, please refer this portion to the Nurse for a proper assessment

Skin

If so, Location: (Skin)

Swelling

Non pitting-if so how much

Wound Location

Wound Stage

Wound type

Gastrointestinal System:

Pain observed

Medication Reminders

Cardiovascular System - vitals

Urinary System

Other Services:

Companionship/Supervision

Laundry/Light Housekeeping

Transportation/Errands

Other Services Needed

Insurance and Payment Information

Primary Insurance Carrier

Insurance ID Number

Group Number

Policy Holder Name

Relationship to Client

Legal Representative Information (if applicable)

Legal Guardian / Power of Attorney Name

Relationship to Client

Phone Number

Address

Service Agreement & Financial Authorization

Service Start Date

Primary Payer

Rate per Hour

Number of Hours per Week

Billing Cycle

Weekly

Upfront

Monthly

Client Admission & Consent for Services

Preferred Method of Communication

Client Preferences & Cultural Needs

Dietary preferences, religious considerations, language, communication needs, Interests, Hobbies, etc.

Religious Considerations: How can we help incorporate yor faith in our care?

Patient Natural Disaster Evacuation Plan

1. Evacuation Destination & Transportation Details

Preferred Evacuation Destination

Evacuation Address

Other (please specify):

Who will provide transportation for your evacuation? (Check all that apply)

2. Medical Equipment and Medication Needs

List any medical equipment or supplies that you will need to take with you during evacuation (e.g., oxygen tanks, mobility aids, catheters):

Please list your current medications to take during evacuation, including dosages if possible:

Are there any special instructions for your medications or medical care during evacuation?

3. Communication Plan During Evacuation

Preferred method(s) of communication(e.g., phone calls, text messages, emails):

Who should be contacted first in an emergency?

Alternate contacts or backup communication plans: