Client Application & Information FORM - Connecticut Community Focus

CLIENT APPLICATION & INFORMATION

Client Name:				Today’s Date:
Client Address	Street/Apt				City	State/Zip
Phone:			Date of Birth	SS#
Ethnicity:				E-mail address
How did you hear about CCF LLC?
Responsible Party Name	First Name			Last Name
Responsible Party Address	Street/Apt				City	State/Zip
Phone:	Day		Evening		Email
Relationship to Client:		Parent	Spouse	Child	Other
Contact responsible party for:			billing		phone contact, and/or
Client Primary Care Physician:				Phone
Case Manager/Therapist:				Phone
Other Specialists:
Emergency Contact				Phone
Address	Street/Apt		City	State/Zip	email
Disability(ies)/Health Condition(s)
Chronic Conditions
Special Physical Considerations
Height:			Weight		Medications (for reminders only)
Allergies:
Special Diet
Assistance Needed and Special Considerations
General Assistance Needed
Special Considerations
In the event of an emergency, please list any specific instructions or duties.
Care Preferences and Matching Information
Preferred days and times for care
Preference regarding the gender of the Care Provider:	No PreferenceFemaleMaleSmokerNon-Smoker					Any other character preference?
Please list type/number of household pets
Please list number of smokers in the house
Other helpful information
I have completed the above information to the best of my ability and knowledge. All of the facts and figures shown here represent true information. In addition, I have reviewed Connecticut Community Focus, LLC. Client Service Agreement and the Client Bill of Rights. I am willing to follow these guidelines while utilizing Connecticut Community Focus, LLC In-Home care services
Signature:					Date:

CLIENT APPLICATION & INFORMATION

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