Client Profile Form

Monday - Friday 09:00 - 17:00

Client Profile

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Please complete this form as fully as possible. The information you provide helps us to match the right caregiver to the client's needs and ensures a smooth start to the care arrangement.

Fields marked * are required. All other fields are optional but the more detail you can provide, the better.

Section 1: Client Details

Client Name *

Address

Telephone

Mobile

Preferred Method of Contact

Date of Birth

Second Client (if registering as a couple)

Client 2 Name

Client 2 Date of Birth

Section 2: Client Representative

Name *

Relationship to Client

Address

Telephone

Mobile

Preferred Method of Contact

Do you hold Power of Attorney?

Yes No Not applicable

Does the Client have an Advanced Decision (Living Will) or DNR (Do Not Resuscitate Order) in place? Are copies available in the home?

Account to be sent to

Payment to Agency/Caregiver to be made by

Alternative Emergency Contact Name

Emergency Contact Telephone

Emergency Contact Mobile

Section 3: GP & Care Start Details

Name of Doctor/GP

GP Surgery Address

GP Surgery Telephone

Date Help is Required

Reason Why Help is Required

Section 4: Care Needs Assessment

What general support and companionship is required?

Does anyone else reside in the home (permanently or temporarily) and do they require any support?

Does the Client receive any additional support from outside agencies or others (friends or family)? Is there a cleaner or gardener?

Is help required to mobilise? Is there any equipment available in the home to assist?

Is help required to transfer from a sitting to standing position? Are there any aids in the home to assist?

Does the Client have a history of wandering or getting lost?

Yes No

What help is required with personal care?

What help is required when visiting the toilet? Are there any aids in place (e.g. commode, incontinence pads)?

Is assistance required during the night?

Yes No

Are there any night time safeguarding aids in place (e.g. sensor mats, call bell, baby monitor)?

Is prompting required with medication? How is this dispensed (e.g. dosset box, blister pack)?

Are there any memory or behavioural problems?

Are there any sensory difficulties (sight, hearing, speech)?

Are there any special dietary requirements?

Please provide current and past medical conditions that may be relevant

Section 5: About the Client

This section helps us find a caregiver who is a great personal match for the client. Please answer in the client's own words where possible.

About the client – family life, whether married, former occupation, etc.

Special interests or hobbies (clubs, regular visits to hairdresser, etc.)

Does the client enjoy their food? What are their favourite things to eat?

Does the client enjoy going out? If so, where?

How does the client like to get around? (walk, taxi, bus or drive)

Is there a car available at the booking?

Yes No

Any religious or cultural needs?

I would describe myself as…

In order for me to feel happy and content I need…

When I am not well or in pain I need…

I am likely to get upset if…

I would feel more relaxed if…

By having a live-in caregiver in my home, I hope to achieve…

Section 6: About the Home

Is it a smoking household?

Yes No

Are there any pets or visiting pets?

Yes No

Is the caregiver required to do the shopping? Are the shops within walking distance?

Is there wi-fi available in the home?

Yes No

What is the nearest train station?

Section 7: Daily Routine

What time does the client like to get up?

What is the morning hygiene routine? Before or after breakfast?

Where does the client prefer to have breakfast?

How does the client like to spend their mornings?

What time does the client like to have lunch?

Is lunch the main meal of the day?

Yes No

Does the client like to rest in the afternoon? If so, how long for?

When can the caregiver take their time off? How will the client manage whilst they are away?

Does the client like to do anything in the afternoon? If so, what?

What time does the client like to have their evening meal?

Is the evening meal the main meal of the day?

Yes No

What time does the client like to prepare for bed?

What time does the client retire for the night?

Is the client likely to need the assistance of their caregiver during the night?

Yes No

Privacy Notice: The personal and health information you provide in this form will be used solely by Care and Choice to arrange and manage your care. We will not share your information with third parties without your consent, except where required by law. For full details please see our Privacy Policy.