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Stay at Home In Little Compton, Inc.

FULLY ACCREDITED & RHODE ISLAND LICENSED IN-HOME CARE PROVIDER

SENIOR SERVICES & LOCAL DIRECTORY LISTINGS

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Client Application for Services

First name

Last name

Email

Phone

How did you find out about us?

Street Address

City

Region/State/Province

Postal / Zip code

Date of Birth

Is the client a smoker?

YES

NO

Does the client live alone?

YES

NO

Height & Weight

Does the client drive?

YES

NO

Is the client homebound?

YES

NO

List all individuals living in the home.

Diagnosis / Current Health Issues*

Please specify personal service needs.

Bathing

Grooming

Dressing

Toileting / Bathroom

Laundry Assistance

Meal Preparation

Pets

YES

NO

List all pets

Who cares for the pets?

Is the client returning from a hospital or rehab stay?

Is the client alert?

Can the client direct home care aides?

If client cannot direct home care aides who is responsible for directing them?

Is the client able to manage medications?

If the client is not independent, what arrangements have been made to administer medications?

Speech Limitations

Sight Limitations

Hand / Arm Mobility

Upper Extremity Mobilty

Leg / Feet Mobility

Full or Partial Paralysis

Oriented to time & place

Anxiety

Agitation

Short term memory loss

Wanders

Depression

Impaired Judgment

Danger to others / agressive

Danger to self

Articulates needs

Sleep Disorders

Drinks alcohol

Needs assistance with meals

Food allergies

If you answered YES to food allergies, please specify

Needs help to ambulate inside

Needs help to ambulate outside

Needs help getting up from a seated position

Needs help to transfer to a commode

Needs help to transfer to a wheelchair

Needs help to get in / out of bed

Contact #1 Name / Relationship

Street Address

City

Region/State/Province

Postal / Zip code

Email

Phone

Invoices

Confirmation of Weekly Schedule

Today's Date

Thank you for your application. We'll get back to you soon.

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