FamilyFirst Care

United States

Woodbridge va 22192

Phone Number

703-469-9819

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CLIENT INTAKE FORM

CLIENT INTAKE FORM

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  • CLIENT INTAKE FORM

Client Admission Packet

🔹 Section 1: Client Info
🔹 Section 2: Emergency Contact
🔹 Home Care Services to be Provided
🔹 Service Schedule
🔹 Cancellations and Modifications

Client or representative must provide at least 24 hours’ notice for cancellations. Services may be modified with written notice. FamilyFirst Care reserves the right to adjust staffing as needed.

🔹Termination of Services

This agreement may be terminated by either party with 7 days’ written notice, or immediately in cases of safety concerns, non-payment, or client misconduct. By signing below, you agree to the terms and conditions of the service agreement and acknowledge receipt of the Client Rights.

🔹 Signature Fields
🔹 Client Rights
  • ✔ Be treated with dignity, courtesy, and respect in a non-discriminatory manner.
  • ✔ Receive services that respect your values, preferences, and cultural background.
  • ✔ Be informed of your care plan, service schedule, and any changes in care.
  • ✔ Participate in decision-making about your care and refuse services.
  • ✔ Voice complaints or concerns without fear of reprisal or discrimination.
  • ✔ Privacy and confidentiality regarding your personal and medical information.
  • ✔ Review your care records upon request.
  • ✔ Be informed of all costs and billing practices.
  • ✔ Receive prompt, safe, and appropriate care.
  • ✔ Have a family member, guardian, or representative exercise your rights if necessary.
  • ✔ Be free from abuse, neglect, and exploitation.