Help us understand who you are
This form helps us understand your living situation, support system, and preferences so we can provide the best possible care.
Your home and daily living environment
Your animal companions
Family, friends, and your care team
Help us understand your daily routines and how we can support your independence at home.
Rate your current level of independence
Tell us about your daily routines and preferences
Select any devices you currently use
Your comfort and communication preferences are important to us.
Help us understand your likes and comfort preferences
Select your preferred ways to receive information
Share any cultural or spiritual practices we should be aware of
Help us ensure your safety and know how to assist you in case of emergency.
Check factors that may increase fall risk
Critical information for emergency responders
Who should we contact in case of emergency?
Share what's important to you and any concerns you'd like us to address.
What do you hope to achieve with home care services?
Let us know about any concerns or special situations
Help us match you with the right caregiver
Please review your information and sign below to complete the assessment.
Please read and agree to the following
Important: By signing below, I acknowledge that the information provided in this assessment is accurate and complete to the best of my knowledge. I authorize Silver Home Care to provide home care services based on the information provided.
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Your information is secure and protected under HIPAA regulations