Client Intake Form | Chris' Companion Care

I'm so glad you’re here. This short form helps me learn more about each client’s needs, preferences, and routine — so I can provide the right kind of personalized support. Whether you or your loved one lives at home, in assisted living, or another care setting, this form is the first step toward friendly, reliable help. Please fill out the form and click submit. -Chris

Name *

Date of birth *

Gender *

Female
Male

Address *

Primary Phone #

Cell/Text

Email address

I understand that while Chris Polle (DBA Chris' Companion Care) will make every effort to keep me or my relative safe and is current on his First Aid training, he is not liable for any injuries/health crises that may occur while together. *

Yes
No

Emergency Contact info (name, relationship, phone number) *

How did you hear about Chris' Companion Care?

Is there anything else you'd like me to know?

Send me a copy

*Services are provided at $25 an hour, minimum 3 hours if outside of central Winnipeg. If a client wants to be driven, a mileage rate of 70 cents per km applies.