Client Information
State of California

 
Client Name:
Age:
Contact Name:
Contact Relationship:
Contact Phone:
Contact Email:
Mailing Address (Optional):
City/State/Zip:
   
       
Mental Condition
Confusion? Yes No  
Memory Problems? Yes No  
Ability to Follow Directions? Poor Fair Good
Diagnosed with Dementia/Alzheimer? Yes No  
  When: 
Physical Health
General Condition? Poor Fair Good
Ambulatory? Yes No Wheel- Chair
History of any Major Medical Condition? Yes No  
Please Explain: When: 
 
Social Factors
Enjoys Socialization? Yes No  
Ability to Drive? Yes No  
Pets? Yes No  
Smokes? Yes No  
Hobbies / Interests:
       
Assistance Needed
Medication      
Grooming      
Shower/Bathing      
Toileting      
Escort      
Other      
Comments?      
       
Preferred  Services
Skilled Nursing      
Assisted Living      
Alzheimer Care      
B and C Home      
In Home Care      
Independent Living      
Comments:      
Monthly Rate (Housing & Care)
     
       
Comments:      
       
Preferred  Location and Type of Housing
Within 15 miles of    
Studio Apt.      
One Bedroom      
Two Bedroom      
       
Time Frame & Best Way to Reach You!


 

 

Home | Care Connection | Commitment | About Us
 Testimonials | Contact Us | Related Links | Care Matters
Housing & Care | Products & Services | Senior Classifieds

Content found in this site is provided for the information and convenience of our website visitors. SCC strongly recommends that you perform due diligence before selecting any service or product. It is your responsibility to verify the accuracy of all information.
Please click here to view our privacy policy.