Step 1 of 9
Services & Number of Hours
Assistive Devices For:
BEHAVIORAL CONCERNS (If applicable)
ADL's (Activity of Daily Living) Please describe level of assistance needed:
Staff Will1. Observe universal precautions.2. Provide general safety supervision.
By signing this document, each party acknowledges that the information contained herein is true and correct. All parties have been provided the opportunity to ask any questions and understand all answers and all parties agree to comply with this agreement. It is also acknowledged that digital (electronic) signature is intended to authenticate this writing and to have the same force and effect as a manual signature. This document will act as a mutual agreement between parties for provision of services.
The member should complete this section. If the member is unable to, the person who knows the member best should complete this section with as much member input as possible.