Please take a moment to complete our Assessment of Home Care Needs.

A Community Home Care representative will call you to discuss how we can be of assistance to you or your loved one(s).
Community Home Care will never share or sell your information. We respect your privacy. All information gathered will be kept strictly confidential.

If you are filling this out for another person, please enter your contact information first followed by the person who would be receiving care.

First Name: * Required

Last Name: * Required

Street Address & Town:

State:

Zip Code:

Phone Number: * Numerals only please.

Email Address: * A valid email is required.

Name of person to receive care (if different from above):

Your relationship to them:

Street Address & Town:

State:

Zip Code:

Phone Number:

Email Address:

How did you hear about Community Home Care?

Flier
Door Hanger
Brochure
Newspaper
Website
Friend or Family
Other, please explain:

Does the person you are inquiring about require any assistance with: 

Personal Care: 

Dressing
Grooming
Bathing
Eating
Oral Care
Getting in and out of a bed
Getting in and out of a chair
Walking
Climbing Stairs
Toileting
Maintaining Continence
Other, please explain:

Other Daily Living Tasks: 

Light housekeeping (dusting, dishes, vacuuming, etc.)
Shopping for groceries or personal items
Managing money/finances
Preparing meals and cleaning up
Using the telephone
Taking medication as prescribed
Transporation within the community
Caring for pets
Other, please explain:

Do any of the following affect the person's daily living:

Vision
Hearing
Memory
Medication taken properly
Decision making
Balance
Mood
Orientation
Other, please explain:

Are there close friends or family members near by?

Please list any diseases or conditions and diagnosis:

Preferred date to start service:

Preferred days:

Preferred times:

Person Community Home Care should contact:  

First Name:

Last Name:

Phone Number:

Email Address:

Other:

Preferred way for Community Home Care to contact this person: 

Phone
Email
Other, please explain: