Individualized Care Plan (ICP)
Please provide the following contact information:
Please help us serve you better by completing our Needs Assessment:
Check the days you/your family will be requiring
Care/Support:
Check what applies to your/your families Care/Support requirements: Full Year Summer only Drop In Temporary or Emergency Care Rotating Schedule Care 24-Hour Care Open Holidays
What daytime hours and/or what nighttime hours will you/your family be requiring Care/ Support?
Language(s) spoken in home:
Special Needs Do you/your family have any special needs? Check One yes no If yes, please provide details.
Environment Is there any smoking in the home? Check One yes no Are there any pets in the home? Check One yes no Do you/your family have a swimming pool? Check One yes no
Meals to be Provided Breakfast Morning Snack Lunch Afternoon Snack Dinner Special Meal Request
Does you/your family have a preferred style of cooking?
What household tasks will you/your family need taken care of (laundry, errands, etc…)?
Do you/your family have a pet that will need to be taken care of? Check One yes no
How long do you/your family anticipate needing 247 CARE?
How did you/your family find out about 247 CARE?
Please list any other concerns or questions you/your family may have:
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