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Live-in Care Customer Enquiry Pre-questionnaire

Thank you for considering our Live-in Care services. To help us better understand your needs and provide the most appropriate care, we kindly ask you to complete the following questionnaire. This survey will gather essential information about the person requiring care, the current care arrangements, and logistical details to ensure we can offer a tailored and efficient service.
Section 1: Enquirer Details
1.Full name:
2.Email address
3.Contact Number
4.Do you have Health and Welfare Lasting Power of Attorney (LPOA) for the person receiving care?
5.Do you have Property and Financial Affairs Lasting Power of Attorney (LPOA) for the person receiving care?
Section 2: Payment Information
6.How will the care be funded
Section 3: Care Recipient Details
7.Full Name
8.Date of Birth
9.Address where care will take place
Section 4: Current Care Information
10.Is there any current professional care service in place?
11.Please describe the current care arrangements
Section 5: Medical Information
12.List any medical conditions and diagnose
Section 6: Logistical Information
13.Expected start date for the Live-in Care
14.Is the property suitable for Live-in Care?
Section 7: Additional Information
15.Any additional information or special requirements you feel may be important to know