Client Profile Form
Complete this form to help us understand your care needs
Primary Contact Information
Name
*
Cell Number
*
Email
*
City, State
*
Power of Attorney
*
Yes
No
Health Care Proxy
*
Yes
No
Person Receiving Care
Name
*
Address
*
Date of Birth
*
Payment Method
*
Select payment method
Private Pay
Long-Term Care Insurance
Medicaid
Veteran
*
Yes
No
Pets
*
Yes
No
Smoking
*
Yes
No
Current Living Situation
*
Private Home
Private Apartment
Independent Living Community
Assisted Living Community
Memory Care Community
Nursing Home
Rehab Facility
Other
Lives With
*
Spouse
Self
Other Family
Other
Current Living Situation
At private home - needs companion care
At private home - needs hands-on care
At senior living community - needs companion care
At senior living community - needs hands-on care
Had medical issue - at Hospital - needs to go home with care
Had medical issue - at Rehab - needs to go home with care
Other
Timing for Care
Select timing
Critical - within 24 hours
Urgent - 24-48 hours
ASAP - within a week
Actively Looking - within the month
Just Exploring - no immediate need
Mobility & Transportation
Ambulation
*
Walks on own
Needs Cane
Needs Walker
Needs Wheelchair
Needs caregiver that drives
*
Yes
No
Care Needs Assessment
ADL Support Needed (check all that apply)
Bathing
Dressing
Toileting
Transferring
Eating
Continence
Special Care Requirements
Hoyer lift
Catheter care
Feeding tube
Wound care
Oxygen
Other (specify)
Schedule & Logistics
Days/Hours Needed
Shift Preference
Morning (6am-2pm)
Afternoon (2pm-10pm)
Overnight (10pm-6am)
24-hour
Live-in
Gender Preference for Caregiver
Male
Female
No preference
Language Preference
English
Spanish
Other
Cultural/Religious Considerations
Referral & Background
How did you hear about us?
Doctor referral
Hospital discharge planner
Online search
Friend/Family
LongIsland.com
Other
Already working with:
Home care agency
Care manager
Therapists
Previous Home Care Experience
Yes
No
Next Steps
Preferred Contact Method
Phone
Email
Text
Best Time to Call
Morning
Afternoon
Evening
Submit Profile Form
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