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Client & Household Information

Responsible Party Section, who’s legally and financially handling the relationship with Serenica. All information shared is kept confidential and used only to help us understand your care needs.

Care Recipient Details

Client Section ensures you know who care is for.

Birthday
Month
Day
Year

Health & Medical Background

Disclaimer: Serenica is a non-medical home care provider. Medical history is requested only to understand the client’s needs and ensure safe support. We do not provide medical care, diagnosis, or treatment.

Any recent hospitalizations or ongoing treatments

Service Needs

Type of care requested:

Multi choice - Choose all that applies.
Frequency of care:
Preferred service schedule:
How many hours of care are you seeking per visit? Serenica provides services with a minimum of 4 hours per visit.

Lifestyle & Preferences

Family Involvement

Will family members participate in care coordination?

Safety & Home Environment

Is the home wheelchair accessible?
Stairs, ramps, or elevators present?
Any home safety concerns (fall risks, clutter, bathroom modifications)?

Financial & Quote Preparation

Serenica also provides documentation for long-term care insurance reimbursement and may work with approved programs when applicable. All services are private pay unless otherwise arranged in advance.

• Photo ID (driver’s license, state ID, or passport) • Medication list (doctor’s printout or self-prepared) • Insurance card or long-term care policy (if applicable) • Advance directives (living will, healthcare POA, DNR, if available) • Emergency contact list (names, phone numbers, relationship)

Consent for Care Quote Preparation

Caring for a loved one can be overwhelming, and you don’t have to do it alone. This consultation allows us to understand your needs and explore how Serenica’s non-medical home care services can support your family.

 

Please share a few details below so we can connect with you and discuss personalized care options.

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