Requested Services & Plan of Care
Please check all services requested:
Personal Care (bathing, grooming, toileting, dressing, personal hygiene assistance)
Companion Care (conversation, reading, games, emotional support, companionship outings)
Light Housekeeping (laundry, vacuuming, organizing, dusting, dishwashing, bedmaking)
Meal Preparation (meal planning, cooking, dietary restrictions, feeding assistance)
Medication Reminders (non-clinical reminders for time and dosage compliance)
Mobility Support / Transfers (bed-to-chair assistance, walking support, repositioning)
Youth Support & Behavioral Redirection (structured supervision, activity engagement)
Transportation / Errands (grocery store, medical appointments, pharmacy runs)
Appointment Scheduling & Calendar Reminders
Assistance with Writing / Reading Mail or Emails
Safety Supervision / Wandering Prevention
Social Engagement (recreational hobbies, companionship activities, socialization)
Pet Care Assistance (feeding, walking, light pet cleanup with client consent)
Respite Care (temporary in-home relief for family caregivers)
Life Skills Coaching (basic budgeting, hygiene routines, time management - youth support)
Technology Help (assistance with phone, tablet, simple electronics, video calls)
Light Yard or Outdoor Help (watering plants, retrieving mail - no heavy labor)
Accompaniment to Community or Faith Events (if permitted)
I consent to the collection, use, storage, and processing of my personal and, where applicable, health-related information, including any data I submit on behalf of others, for the purpose of evaluating or fulfilling my request made through this form. I understand this will be handled in accordance with the Privacy Notice.
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