Full Name of Client

Contact Information:

Phone:

Email:

Address (within Orange, Seminole, Osceola, or Brevard counties):

Emergency Contact Information

Name:

Phone:

Preferred Caregiver Gender

FemaleMale (only if specifically requested)

Medical History & Current Medications (if applicable):

Special Care Instructions (e.g., dietary needs, mobility assistance, specific care routines):

Consent to Share Information with Caregivers

I consent to share my information with caregivers for the purpose of receiving care services.

Acknowledgement of Surprise Visits & Company Policies

I acknowledge and agree to the company's policies, including surprise visits and performance monitoring.

How Did You Find Us? (e.g., online search, social media, referral, etc.)

Care Services Needed

Companionship (conversation, reading, activities)Medication RemindersMeal Preparation (non-medical assistance in preparing meals)Light Housekeeping (e.g., cleaning, organizing, laundry)Transportation (for appointments, errands, etc.)Social Engagement (going for walks, attending events, etc.)Board Games (playing games like chess, cards, etc. for mental stimulation)Virtual Therapy/Consultation (a deep communication service provided by an experienced therapist, non-licensed)Other

Preferred Care Schedule

Days Needed (check all that apply):

MondayTuesdayWednesdayThursdayFridaySaturdaySunday

Preferred Hours (choose your preferred time range):

Morning (8 AM - 12 PM)Afternoon (12 PM - 4 PM)Evening (4 PM - 8 PM)Flexible (no preference)

Consent and Acknowledgment

I acknowledge that the information provided in this form is accurate and true to the best of my knowledge. I understand that providing false information may result in a delay or termination of services.

I consent to NewDay Senior Care contacting me for follow-up and scheduling of services.

Date of Application