Client plan

Community Support Solutions

PO Box 1237

Edmonds, WA 98020

Phone 425-672-8787 Fax 425-670-1640

HOME CARE PLAN

Client Name: ________ Birthdate___________________

Address, City, State, Zip Code:

_____________________________________________________________________________________________________

Mailing Address (If different than residence) ___________________________________________________________________________________

Phone Number: _____________________Email: _____________________________________

Do you live independently?  Yes  No

Primary Parent or Guardian: _____________________________________

Primary Mailing Address (If different than client) ___________________________________________________________________________________

Phone Number: _____________________ Email: _____________________________________

Hours and Days of Service Needed:

Sun	Mon	Tue	Wed	Thurs	Fri	Sat

Care Duties

Personal care:

Bath: (please circle) Tub Shower Sponge

Skin care Shave Shampoo Foot Care

Lotion/Massage Oral Hygiene Peri Care/Catheter Care

Urine Checks/Diaper Change

Nutrition/Meal Preparation:

Preparation Meal: (please circle) Breakfast Lunch Dinner Snacks

Feed

Force Fluids- glasses per day

Special Diet _____________________

Record intake

Grocery shopping

Activities:

Bed rest

Turn and Position

Dangle Independent

Up with Help only (assist to bathroom)

Ambulate (please circle) Ad Lib Cane Walker Crutches

ROM (Range of Motion)

Specific Exercises (please specify): _______________

Wheelchair

Transfer

Please Continue to next page

Household Services:

Clean Client Area (please specify): _______________

General Cleaning (please circle) Kitchen Bedroom Bathroom

Client’s Personal laundry

Linen Change: (please circle days) Mon, Tues, Wed, Thurs, Fri, Sat, and Sun

Client Special Interests:

Does Client have allergies: Yes No If so what? ________

Does Client smoke? Yes No

Provider Preference: Non-Smoking Male Female

Do you require caregiver to have a car? Yes No

Household Rules: Yes No

Please specify: ______________________________________________________________

___________________________________________________________________________

Home Environment/Safety Assessment: Yes No

Household Pets? Yes No What kind? (Names) ____________

Physicians Name and Telephone number: ____________________________________________

Emergency Name and Telephone number: ____________________________________________

Special Instructions and Other information:

Directions to house: ___________________________________________________________________________

Family Members in house:

Name: ______ Relation: _____

Name: ______ Relation:

Case Manager’s Name: __________________ Phone: ____

Care Giver Signature Date __________

Leave this empty:

Your legal name

Your email address

Timestamp

Audit

January 29, 2021 2:26 pm PST

Client plan Uploaded by Priscilla Monahan - Priscilla@cssow.com IP 172.92.219.168