Relationship to Client – or Client’s Name
Date of Birth
Client’s current address – if different than above
How did you hear about Savvy Seniors Services?
Has there been any contact with your local health authority?
Assessment by a Case Manager?
Is the client receiving any homecare services?
If yes, what?
Does client have a chronic illness or terminal disease?
Is client experiencing memory loss, confusion or dementia?
Has client signed a Power of Attorney or Representation Agreement?
Is client financially able to consider Private Care Homes as well as Public Care?
Briefly describe client’s current living situation and why more care is needed