Client Care Plan

👤 Client Information

First Name *

Last Name *

Age

Phone *

Address / Location Where Services Are To Be Provided

City

Province

Postal Code

Client Email

🩺 Client Care Plan

Date Services Requested *

Client General Condition and Concerns *

Care Plan Services

Service	Required
1. Assist with Bathing
2. Assist with Dressing
3. Assist with Personal Hygiene
4. Assist with Eating
5. Meal Preparation
6. Light Housekeeping
7. Assist with Exercise and Mobility
8. Supervise/Remind Client to take Medication
9. Companionship
10. Errands in Workers own Vehicle at $20/day additional charge
11. Accompany Client to Appointments (Not using Workers own Vehicle, Client pays for Workers Transportation)

📅 Start Date

Care Start Date *

🕐 Schedule (4 HRS Minimum)

	4 HRS	5 HRS	6 HRS	8 HRS	10 HRS	12 HRS	24 HRS
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Start Time Per Day

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

📞 Contact Information

Family Doctor *

Name

Phone

In Case of Emergency Call *

Name

Relationship

Phone

📧 SDM / POA

SDM/POA Email

✍️ Signature of Client / POA / Guardian

Sign below using your finger or mouse:

✅

Care Plan Submitted!

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