Request Client Services | Hope Home Healthcare

Name and relationship of individual filling out this form

Individual requesting services — first name or initials

City, county, and general area where the individual lives (e.g., SW Portland).

When does the individual need services

What days and times does the individual need support each week?

Does the induvial needs medical supports and if so please give a brief description.

Individual’s preferences for DSP/EP (e.g., age, gender, or other requirements)

Does the individual experience any mobility challenges or use adaptive equipment (e.g., wheelchair, walker, braces)?

Does the individual require assistance with hygiene, toileting, and/or other ADLs? If so, please provide a brief description.

Does the individual have any diagnosed mental health conditions or a history of significant mental health concerns?

Does the individual have a Positive Behavioral Support Plan? Have they completed a Functional Behavior Assessment?

Is there any further relevant information related to the individual's support needs that should be noted?

What activities does the individual currently participate in or enjoy?

What are the individual's identified short- and long-term goals?

Is the individual currently working? If so what supports and services do they have or need?

If the individual is not working do they have employment or Discovery goals?

Does the individual demonstrate reliability and consistency with scheduled services and commitments?