Client Data Form

We have several easy ways for you to submit your information to us:

1.
Fill out and submit the form below online
2.
Download and fill out the PDF version of our Client Data Form
(you must have Adobe Reader, download your free copy here)
3.
Contact Us to schedule an appointment for one of our representatives to meet with you in person
4.
Request a form be sent to you by mail.

Take a moment to fill out the following information so that we are better able to serve you!


Postal Mail
Phone
Email

Morning (8a - 12p)
Day (12p -6P)
Evening (6p - 8p)

For whom are you interested in getting information regarding Quality Living Solutions' services?

Name of person (other than self) whom services are being sought?


PLEASE FILL OUT REMAINING INFORMATION FOR THE PERSON WHOM SERVICES ARE BEING SOUGHT (CARE RECIPIENT)


Gender:

When do anticipate services/products will need to begin?

Indicate number of hours of support services the care recipient requires:
 

What, if any, existing medical conditions does the care recipient currently have? (mark all that apply)
 
Other (describe):

What type of medical/care assistance is the care recipient currently utilizing? (select all that apply)


Is the care recipient currently working:

If yes, what is the work schedule?
(Nearest hour to hour)

Mon to Tue to
Wed to Thu to Fri to
Sat to Total week:

How far from home?

Mode of transportation to/from work:

What nutritional / allergy issues should we know about the care recipient?
Allergies:
Eating habits:
Eating disorders:
Daily medications:
Other:

What types of activites, hobbies, interests does the care recipient enjoy? (please describe)

Are there any shopping excursions or outings that the care recipient particularly enjoys? (please describe)

What spiritual/religious needs of the care recipient need to be considered? (please describe)

Is the care recipient willing and/or able to relocate in order to receive services?

Please provide the desired location for the service(s) or products the care recipient is seeking.

From the list, please select the care recipients preference for where care is provided: (select one)
 

Please select any services that the care recipient needs: (select all that apply)

Please explain any specific services that are required/needed for the care recipient:

Does care recipient have a vehicle or access to a vehicle for transportation?

Is the care recipient a veteran of a branch of the armed services?

If "yes" please indicate branch of service:

How does the care recipient feel about recieving infomation from Quality Living Solutions, LLC and/or our affiliates?

How will the services and/or products be paid for, what is the primary funding source for the care recipient?

Does the care recipient have a budget for "out-of-pocket" expenses? Yes

If so, approximately how much? How often?

Please explain any additional information about the care recipient that would better help us serve them.

Thank you for taking the time to fill out our client data form. Your responses will be used by Quality Living Solutions, LLC to provide you with the best possible services. ALL INQUIRIES ARE COMPLETELY CONFIDENTIAL. A Quality Living Solutions, LLC representative will be in contact with you shortly!

                                                                              © 2010 Quality Living Solutions, LLC