Register Care Needs

Client Name *

First

Last

Street address *

City *

Post Code *

NoK/Advocates Name *

First

Last

Email *

Phone No. *

How many people require care? *

• One
• Two
• Other

What Kind of care is required? *

• Personal Care
• Companion Care
• Health-related Care
• All of the above
• Other

Specify other care needs

Which of the following do you need help with? *

• Housekeeping
• Medication
• Personal Care
• Shopping
• All of the above
• Other

Specify other needs

Which of the following medical conditions or care needs does the client have? *

• Dementia
• Incontinence
• Parkinsons Disease
• Learning Difficulties
• Diabetes
• Arthritis
• Other

Specify any other conditions

How many days per week is care required? *

• One
• Two
• Three
• Other
• Live-in

Specify other option

How long will each visit last? *

• 1 Hour
• 2 Hours
• 3 Hours
• Other

Specify other option

What time(s) of the day will the visits take place? *

• Mornings
• Afternoons
• All day
• Overnight

Specify other option

What is your current mobility level? *

• Full mobility
• Some assistance required
• Requires a wheelchair or mobility device

Specify other option

When do you want care to begin? *

• Soonest
• Next Week
• Next Month
• Still deciding

Specify other option

Do you need overnight care? *

• Yes, regularly
• Yes, occasionally
• No

Specify other option

Do you have any specific preference for your caregiver? *

• Non-smoker
• Fluent in a specific language
• Male caregiver
• No specific requirements
• Female caregiver

Will you require care on the weekends? *

• Yes, regularly
• Yes, occasionally
• No

Any additional information

Submit