admin – Special People

novembro 20, 2020

Published by admin on novembro 20, 2020

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SCHEDULE A FREE HOME CARE ASSESSMENT

This is a confidential registration of interest form.

Filling it out does not imply an immediate contract, but it allows us to better understand your needs and evaluate the best way to support you. After submission, our team will contact you to present personalized service options.

SCHEDULE A FREE HOME CARE ASSESSMENT

This is a confidential registration of interest form.

Identification Details

Name

Date of birth

Name of parent/guardian:

Home address:

Post code:

Home phone:

Work phone:

Mobile phone:

E-mail:

Emergency Contact

Name of emergency contact:

Relationship to client:

Phone:

User Information

Description of diagnosis / special needs:

Medication required and/or clinical procedures the support worker may need to carry out:

Does the service user display any behaviour that the support worker should be aware of?

Does the service user have any allergies or dietary restrictions?

Other specific requirements: Objectives of the support package / activities to be carried out:

Service Schedule and Duration