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 *

Client's age *

Gender *

Female
Male
Non-Binary
Prefer not to say

Address *

Primary Phone # *

Cell/Text

Email address

Privacy & Consent *

Chris follows safe-work and transportation practices and is current on CPR/First Aid. I understand some risks remain inherent to everyday activities and appointments, and I agree to communicate any health or mobility concerns in advance.

Transportation *

I acknowledge that transportation is pre-arranged and billed in addition to Chris’s hourly rate at $0.75/km. I confirm the client will be seated and belted, and can transfer independently or with Chris’s assistance to/from a wheelchair.

Emergency Contact Name *

Emergency Contact Relationship *

Emergency Contact Phone # *

How did you hear about Chris' Companion Care?

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

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