Client Intake Form

As a client of Comfort Care, you have the right to receive care that respects your dignity, independence and personal values. We are committed to providing high-quality, compassionate and ethical home care services. By signing below, you acknowledge that you have been informed of and understand your rights as a client, which include:

✔ Respect and Dignity
To be treated with courtesy, respect and consideration at all times, without discrimination.

✔ Safe and Quality Care
To receive safe, competent and professional care that meets your assessed needs and follows applicable laws and standards.

✔ Privacy and Confidentiality
To have your personal, medical and financial information kept confidential, except where disclosure is required or permitted by law.

✔ Participation and Choice
To be involved in decisions about your care, including care planning, scheduling and changes to services and to refuse or discontinue services at any time (subject to service agreements).

✔ Information and Transparency
To receive clear information about services provided, fees, billing practices, caregiver roles and any changes that may affect your care.

✔ Continuity of Care
To be informed in advance, whenever possible, of any changes to your care plan or assigned caregiver.

✔ Freedom from Abuse or Neglect
To receive care free from physical, emotional, financial or verbal abuse, neglect or exploitation.

✔ Complaints and Concerns
To express concerns or complaints about your care without fear of retaliation and to have those concerns addressed promptly and fairly.

✔ Termination of Services
To receive reasonable notice if services are to be discontinued, except in cases of immediate risk or non-compliance with service agreements.

Comfort Care is committed to the safety and well-being of our clients and caregivers. While our caregivers provide support and assistance, they are not emergency responders and do not replace medical professionals or emergency services.
Emergency Procedures
✔ In the event of a medical emergency, injury, fire or other immediate danger, caregivers are instructed to contact emergency services (911 or local emergency number) immediately.

✔ Caregivers will follow your provided emergency instructions to the best of their ability until emergency services arrive.

✔ Caregivers may notify the designated emergency contact(s) and the agency as soon as reasonably possible.

✔ For non-emergency medical concerns, caregivers will follow the care plan and notify the agency or designated contact as appropriate.
Client Responsibilities
✔ To provide accurate and up-to-date emergency contact information, medical conditions, allergies, medications and physician details.

✔ To inform Comfort Care promptly of any changes to health status, emergency contacts or care instructions.

✔ To maintain a reasonably safe home environment and inform the agency of known hazards or risks.

✔ Comfort Care will provide services as outlined above with trained, screened staff.

✔ Services are non-medical unless otherwise authorized.

✔ Client agrees to provide a safe environment for staff to perform duties.

✔ Client or responsible party must notify the agency of any changes in health, medications, or environment that may affect care.

✔ Either party may terminate services with written notice.

✔ Comfort Care will provide services as outlined above with trained, screened staff.

✔ Services are non-medical unless otherwise authorized.

✔ Client agrees to provide a safe environment for staff to perform duties.

✔ Client or responsible party must notify the agency of any changes in health, medications, or environment that may affect care.

✔ Either party may terminate services with written notice. I consent to receive nonmedical homemakers and companion services provided by Comfort Care. I understand that these services are non-medical in nature.