Recipient of Care *

Service for Self

Service for Someone Else

Service for Someone Else - Relationship

City Name *

Name of Community or Building Complex *

Phone Number (Main): *

Phone Number (Secondary) *

Below is a list of non-medical caregiving services that help individuals maintain their

independence and comfort in their own homes. Please use the checklist below to help

us better understand assistance required:

Daily Activities

Bathing – Assistance with showering, bathing, or sponge baths.

Dressing – Helping with putting on clothes and footwear.

Grooming – Assistance with hair care, shaving, and nail care.

Oral Hygiene – Helping with brushing teeth, dentures, and mouthwash.

Toileting – Assistance with using the bathroom and maintaining hygiene.

Incontinence Care – Managing incontinence and changing adult briefs.

Mobility – Helping with moving around the home, transferring from bed to chair, or wheelchair use.

Walking Assistance – Assisting with walking or using mobility aids like walkers.

Eating – Feeding assistance or helping prepare meals for those with difficulty eating.

Positioning in Bed/Chair – Helping reposition to prevent discomfort or pressure sores.

Grocery Shopping – Shopping for groceries, medications, or household supplies.

House Cleaning – Light cleaning, such as dusting, vacuuming, and tidying up.

Laundry – Washing, drying, folding, and putting away clothes or linens.

Medication Management – Reminders to take medications or assistance with organizing pills.

Transportation – Driving or arranging transportation for appointments, errands, or social outings.

Organizing Appointments – Scheduling and managing medical or personal appointments.

Companionship – Engaging in conversation, games, or social interaction.

Emotional Support – Providing encouragement and emotional care.

Reading Aloud – Reading books, magazines, or newspapers for those with visual or cognitive impairments.

Social Outings – Accompanying on visits to friends, family, or community events.

Exercise Assistance – Helping with light physical activity, stretching, or exercises recommended by a healthcare provider.

Hobbies and Crafts – Helping engage in hobbies like puzzles, crafts, or gardening.

Pet Care – Assisting with feeding, walking, and caring for pets.

Emergency Planning – Helping to prepare and execute emergency plans in case of natural disasters or accidents.

Caregiver Respite – Providing temporary relief for primary caregivers by taking over responsibilities for a short period.

Can you refer anyone to us who resides within the same buildings, complex, or care facilities that may have an interest in our Split Shift Caregiving?

Yes

Please provide their contact details so that we may reach out to make an introduction and confirm their interest in this service:

Phone Number (Secondary)

Thank you for your interest in our Split Shift Caregiving service, we will reach out to you

to discuss this further.