Plan of Care

This Plan of Care records the client’s current non-medical care needs and preferences. It forms part of the Client Service Agreement and will be reviewed and updated as needs change. It defines the support to be provided and the tasks that are not permitted (for example, no medication administration and no medical procedures).

Client Details

Client name *

Date of birth

Address *

Phone *

Email (for a confirmation copy)

Emergency Contact

Name

Relationship

Phone

1. Care Goals

What the client wants to achieve — comfort, independence, safety, companionship, etc.

2. Services Required

Personal care (bathing, dressing, grooming) Companionship / supervision Meal preparation Light housekeeping Mobility assistance Errands (non-medical) Other:

3. Mobility & Safety

Mobility level

Independent Needs assistance Uses walker / wheelchair

Fall risk

Yes No

Safety concerns (stairs, pets, smoking, etc.)

4. Daily Routine & Preferences

Morning routine, meals, likes/dislikes, cultural or religious preferences.

5. Health & Support Information (Non-Medical)

Diagnosed conditions (optional)

Allergies (if any)

Cognitive status (if applicable)

Alert Memory concerns

6. Schedule of Care

Days of service

Time of service

Start date

7. Tasks NOT Permitted

These boundaries always apply. You may add any additional restrictions below.

No medication administration
No medical procedures

Additional tasks not permitted (optional)

Acknowledgement

I confirm that this Plan of Care reflects the client’s current needs and preferences.

Client / Substitute Decision-Maker — printed name *

Relationship to client (if applicable)

Signature *

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Client Details

Emergency Contact

1. Care Goals

2. Services Required

3. Mobility & Safety

4. Daily Routine & Preferences

5. Health & Support Information (Non-Medical)

6. Schedule of Care

7. Tasks NOT Permitted

Acknowledgement

Thank you — your Plan of Care was submitted