Client Questionnaire Client Questionnaire This questionnaire will allow us to connect with you in the best way possible. CLIENT INFORMATIONClient Name First Last Date of Birth MM slash DD slash YYYY AgeParent Name First Last Email PhoneWhat are the client's major cross streets How did you hear about TLC Services? When are you wanting services? Monday Tuesday Wednesday Thursday Friday Saturday Sunday Services Needed IN HOME OFFICE Habilitation: Number of times per week? Attendant Care: Number of times per week? Speech: Number of times week? Tutoring? Number of times week? & Subjects Respite: MATCHING PREFERENCESDescribe your ideal provider:Gender Preference Female Male Will you require transportation? Yes No Do you have any family or friends you would like to provide services? Yes No What is your backup plan? 2 hours Today 48 hours Next visit NEEDS: (skip for Tutoring & Speech)Each client we serve has a variety of individualized needs. The information you provide below will help us as we attempt to find a good match for you.Uses a Wheelchair Yes Maybe No Assistive Devices Yes Maybe No Aggression Yes Maybe No Medical Needs Yes Maybe No Diaper Needs Yes Maybe No Is Tube Fed Yes Maybe No Uses a Communication Device Yes Maybe No Has Seizures Yes Maybe No Med Administration Yes Maybe No Comments:EmailThis field is for validation purposes and should be left unchanged. Δ
