Client Information

     
   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

      
 

Board and Care 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 | Why SCC? | Commitment | The SCC Team
 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.