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Serving Sonoma County & surrounding North Bay communities

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Call (707) 703-5170

New Client Enrollment & Care Assessment Form

Please complete the information below so we can better understand your care needs and create a personalized care plan for you or your loved one.

Step 1 of 5

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CLIENT INFORMATION

Client Full Name:

DOB (MM/DD/YYYY):

MM slash DD slash YYYY

Gender:

Primary Language:

Phone Number:

Email Address:

Home Address:

EMERGENCY CONTACT INFORMATION

Primary Emergency Contact:

Relation to Client:

Phone Number:

Alternate Phone Number:

Email Address:

Secondary Emergency Contact:

Relation to Client:

Phone Number:

Alternate Phone Number:

Email Address:

RESPONSIBLE PARTY INFORMATION [If different from Client]

Name:

Relationship:

Phone Number:

Email Address:

Billing Address:

PHYSICIAN INFORMATION

Primary Physician Name:

Clinic/ Hospital Name:

Phone Number:

Fax Number:

Clinic Address:

INSURANCE INFORMATION [Optional - If Applicable]

Insurance Provider:

Policy Number:

Member ID Number:

ALLERGIES & MEDICATION

Allergies:

List of Current Medications:

CLIENT CONDITION & CARE NEEDS

Please check all that apply:

No Restrictions

Diabetic Diet

Low Sodium

Soft Foods

Pureed Diet

Vegetarian

Vegan

Gluten-Free

Low Sugar

Heart Healthy Diet

Food Allergies:

Foods to Avoid:

Favorite Foods/Meals:

Special Meal Preparation Instructions:

REQUESTED SERVICES

Please check all services requested:

Personal Care Assistance

Bathing & Grooming

Dressing Assistance

Meal Preparation

Medication Reminders

Light Housekeeping

Laundry Assistance

Transportation/Errands

Mobility & Transfer Assistance

Dementia/Memory Care

Companion Care

Respite Care

Live-In Care

Overnight Care

Hospice Support

Other

DIETARY PREFERENCES & RESTRICTIONS

Please describe the client’s current condition, diagnosis, limitations, or care needs:

Does the client use any mobility equipment?

Walker

Wheelchair

Cane

Hoyer Lift

Hospital Bed

Oxygen

Other

SCHEDULE REQUEST

Requested Start Date:

MM slash DD slash YYYY

Preferred Schedule:

Full-Time

Part-Time

Weekdays

Weekends

Overnight

Live-In

Preferred Hours:

HOME & SAFETY INFORMATION

Are there pets in the home?

Yes

Smoking in the home?

Yes

Any known safety concerns in the home?

CLIENT RIGHTS & CONSENT

I certify that the information provided is accurate and complete to the best of my knowledge. I authorize SafeHaven Fiji In-Home Care Agency LLC to provide non-medical in-home care services as agreed upon and understand that care plans and schedules are based on client needs and caregiver availability.

Client/Responsible Party Name

Date:

MM slash DD slash YYYY

Client/Responsible Party`s Signature

About SafeHaven Fiji In-Home Care Agency LLC:

SafeHaven Fiji In-Home Care Agency LLC is a licensed and bonded Home Care Organization dedicated to providing compassionate, reliable, and personalized in-home care services.

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Licensed & Ready to Serve

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24/7 Phone Support Available

Have questions or need to arrange care? Call us anytime.

(707) 703-5170
Email:
info@safehavenfiji.com
Location:
Serving Sonoma County and surrounding North Bay communities, including Santa Rosa and nearby areas.

Request a Care

New Client Enrollment & Care Assessment Form

CLIENT INFORMATION

EMERGENCY CONTACT INFORMATION

RESPONSIBLE PARTY INFORMATION [If different from Client]

PHYSICIAN INFORMATION

INSURANCE INFORMATION [Optional - If Applicable]

ALLERGIES & MEDICATION

CLIENT CONDITION & CARE NEEDS

REQUESTED SERVICES

DIETARY PREFERENCES & RESTRICTIONS

SCHEDULE REQUEST

HOME & SAFETY INFORMATION

CLIENT RIGHTS & CONSENT

About SafeHaven Fiji In-Home Care Agency LLC:

Quick links

Other links

Social Media

24/7 Phone Support Available