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Client Name:
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Today’s Date:
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Client Address
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Street/Apt
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City
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State/Zip
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Phone:
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Date of Birth
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SS#
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Ethnicity:
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E-mail address
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How did you hear about CCF LLC?
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Responsible Party Name
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First Name
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Last Name
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Responsible Party Address
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Street/Apt
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City
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State/Zip
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Phone:
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Day
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Evening
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Email
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Relationship to Client:
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Parent
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Spouse
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Child
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Other
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Contact responsible party for:
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billing
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phone contact, and/or
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Client Primary Care Physician:
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Phone
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Case Manager/Therapist:
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Phone
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Other Specialists:
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Emergency Contact
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Phone
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Address
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Street/Apt
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City
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State/Zip
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email
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Disability(ies)/Health Condition(s)
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Chronic Conditions
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Special Physical Considerations
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Height:
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Weight
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Medications (for reminders only)
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Allergies:
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Special Diet
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Assistance Needed and Special Considerations
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General Assistance Needed
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Special Considerations
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In the event of an emergency, please list any specific instructions or duties.
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Care Preferences and Matching Information
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Preferred days and times for care
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Preference regarding the gender of the Care Provider:
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Any other character preference?
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Please list type/number of household pets
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Please list number of smokers in the house
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Other helpful information
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I have completed the above information to the best of my ability and knowledge. All of the facts and figures shown here represent true information. In addition, I have reviewed Connecticut Community Focus, LLC. Client Service Agreement and the Client Bill of Rights. I am willing to follow these guidelines while utilizing Connecticut Community Focus, LLC In-Home care services
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Signature:
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Date:
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