PREMIER CHOICE HOME CARE SERVICES
SERVICE PLAN
NAME: ________________________________________ D.O.B _________________
ADDRESS: _____________________________________
_____________________________________
Functional Limitations:
____________________________________________________
____________________________________________________
____________________________________________________
Diagnosis by Healthcare Provider____________________________________________
Allergies: ______________________________________________________________
Other: _________________________________________________________________
Duties to be provided by private companion/caregiver:
___ Private Duty Hrs. _____ Shift ______to_______ Live In_____
___ Dressing ___Undressing
___ Bathing
___ Toileting ___ Assist with Incontinence Protection
___ Assist with Transfers
___ Feeding
___ Bed care ___ Positioning ___Turning
___ Assist with Ambulation
___ Breakfast ___ Lunch ___ Dinner
___ Encourage Eating ___Encourage Liquids
___ Assist with exercise
___ Make bed ___Turn down
___ Change Linens ___ Empty Trash
___ Light Housekeeping (Incl. Dishes)
___ Laundry
___ Monitor Safety
Other __________________________________________________________________
I certify that I have read and understand the services provided by Premier Choice Home
Care Services
I certify that that I am aware that the services, provided by Premier Choice Home Care
Services, are provided by private companions and caregivers.
I am also aware that Premier Choice Home Care Services is do not provide housekeeping or
maid services but a service that provides private companions and caregivers to assist the
client with minimal housekeeping service to ensure a safe and healthy environment.
Client Signature: __________________________________ Date: __________________
Premier Choice Home Care Rep.: ______________________ Date: _________________
Premier Choice Home Care Services
P.O. BOX 362166
Decatur, Georgia 30036-2166