Request Care | Bluegrass Personal Care Services

Service Request & Pre-Intake Screening Form

Bluegrass Personal Care Services, LLC

This form is used to request information about non-medical personal care services. Submission of this form does not guarantee services or establish a client relationship. Information will be reviewed by agency management to determine service availability and fit.

Client/Responsible Party Information

Client Name

Responsible Party Name (if applicable)

Phone

Email

Preferred Method of Contact

Phone

Email

Text

Service Needs (check all that apply)

Schedule & Location

City / ZIP Code

Days of Service Needed

Approximate Hours Per Visit

Preferred Start Date

Home & Safety Screening

Pets in Home

Yes

No

Aggressive or violent behavior present?

Yes

No

Firearms in the home?

Yes

No

Secured

Smoking permitted in the home?

Yes

No

Stairs or fall hazards present?

Yes

No

Transportation

Do you anticipate needing transportation assistance as part of your services?

Yes

No

Unsure / Would like to discuss

If yes, what type of transportation assistance may be needed?

Errands

Appointments

Social Outings

Other

Transportation services are subject to availability and agency approval.

Acknowledgments

I understand services are private-pay at this this time and subject agency rates.

I understand submission of this form does not guarantee services and does not establish a client relationship.