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Lighthouse Care
Plan of Care & Caregiver Contract Form
Personal Information
Plan of Service For
*
This field is required.
Date of Birth
Height
Weight
Advance Directive
Emergency Contacts
Emergency Contact #1
Phone Number
Email Address
Emergency Contact #2
Phone Number
Email Address
Medical Information
Chronic or Acute Medical Conditions
Allergies
Special Diet
Hearing Aides
Select
Yes
No
Incontinent
Select
Yes
No
Assistance Bathing
Select
Yes
No
Driver’s License
Select
Yes
No
Medication List
Caregiver Contract
Client Name
*
This field is required.
Emergency Contact
Services Provided
Personal Care
Medication Reminders
Light Housekeeping
Transportation/Errands
Meal Preparation
Others
Schedule Start Date / Hours
Compensation
Payment Methods
Cash
Check
Signatures
Additional Notes
Submit Complete Form
