Client Care Service Plan

EMERGENCY INFORMATION

CLIENT INFORMATION

ACTIVITIES of DAILY LIVING (ADLS)

Please indicate and briefly describe the client’s level of function for each ADL.

I=Independent                 A=Assistance needed from caregiver                D=Dependent upon caregiver

TYPES and SCHEDULE of SERVICES to be PROVIDED TO CLIENT

CLIENT’S PERSONAL INTERESTS, FAMILY LIFE AND DAILY ROUTINE

METHOD OF PAYMENT

Bill to Information:

Long Term Care Company Information:

POWER OF ATTORNEY INFORMATION

OFFICE USE

Hourly Rate for Two People:

Bath Visit

Mileage Fee

Deposit Fee

Assurance Home & Convalescent Car, Inc. has a 24 hour cancellation policy.  Client will be billed the rate due for the entire shift if client fails to give Assurance’s office staff the required 24 hour notice of cancellation of shift.

The client will be billed at time and one half of the regular rate on holidays.  Please refer to the Assurance Home & Convalescent Care, Inc. Service Agreement for a list of holidays.

The client will be billed at time and one half of the regular rate if caregiver works over 40 hours in a week for said client.

Or