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St. John's 709 757 3550
Outside St. John's 709 227 7500
CareGivers - Online Assessment

At CareGivers we know acquiring home care can be a difficult decision. We have created a needs assessment to help us determine if home care is right for you or your loved one.

Upon submission of the assessment, it will be sent to one of our client care managers who will review the information and contact you within two business days.

What is the relationship between you and the person who requires care? Myself
Parent
Grandparent
Child
Aunt/Uncle
Friend
Other
Desired Start Date
What personal care needs does this person have? (check all that apply) Requires assistance getting
in and out of bed
Requires assistance dressing and undressing
Requires assistance getting in and out of the tub
Needs assistance using the commode and/or incontinence
management products
Unsure
Other (please specify below)
Does this person have any homemaking needs? (check all that apply) Cleaning/Laundry
Light housekeeping
Grocery shopping
Cooking meals
Companionship
Other (please list below)
Does this person use any special equipment? (check all that apply) Wheelchair
Grab Bars
Hospital Bed
Walker
Transfer Board
Cane/Crutches
Bath Bench
Oxygen
Commode
Transfer Bar/Pole
Lifts
Restraints
Other (please list below)
Does this person have any health problems? (check all that apply) Arthritis
Cancer
Stroke
Heart disease
Open wounds
Alzheimer's
Dementia
Pain
Parkinson's disease
Diabetes
Brain injury
Lung problem
Recovering from surgery
None
Other (please list below)
What are your expected outcomes from receiving homecare? (check all that apply) Promote independence
Return to self-care
Support/maintain comfort
Prevent deterioration
Maintain wellbeing through caregiver relief
Unsure
Other (please list below)
Comments:
How did you hear about CareGivers? From a friend
Internet Search
Phone book
Radio
Other
Your Name:
Address:
Email Address:
Phone Number (Daytime):
SPAM:

To prevent abuse via SPAM, please enter the 2nd letter (the letter A) of the word, "Care" in the text box above.


  

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