Client Care Plan

Client Information

Full Name

Client ID / Record Number

Address / Location of Care

Date / Time

Primary Contact Person / Responsible Party

Phone

Gender

Relationship to Client

Emergency Contact Information

Primary Emergency Contact

Secondary Emergency Contact

Preferred Hospital / Medical Facility

Relationship

Primary Physician / Care Provider

Phone

Phone / Fax

Health History and Medical Information

Primary Diagnoses / Conditions

Secondary Diagnoses / Conditions

Allergies

Current Medications (including dosage and frequency)

Past Surgeries or Hospitalizations

Cognitive or Behavioral Considerations

Special Needs / Equipment Required

Physical Limitations / Mobility Requirements

Client Preferences and Cultural Considerations

Preferred Language

Preferred Communication Method

Cultural or Religious Practices Affecting Care

Personal Care Preferences

Dietary Restrictions or Preferences

Assessment of Needs

Activities of Daily Living (ADL) Assistance Needed

Instrumental Activities of Daily Living (IADL) Assistance Needed

Behavioral or Mental Health Support Needed

Other

Goals of Care

Short-Term Goals (to be achieved within 1–3 months)

Textarea

Long-Term Goals (to be achieved within 6–12 months or ongoing)

Textarea

Planned Interventions and Services

Service / Intervention

Frequency / Schedule

Service / Intervention

Frequency / Schedule

Service / Intervention

Frequency / Schedule

Responsible Staff / Contractor

Expected Outcome / Measure of Success

Responsible Staff / Contractor

Expected Outcome / Measure of Success

Responsible Staff / Contractor

Expected Outcome / Measure of Success

(Add additional interventions as needed)

Monitoring and Evaluation

Frequency of Care Plan Review

Notes / Observations from Previous Review

Method of Progress Evaluation

Progress Toward Goals

Other

Date of Next Review

Signatures and Acknowledgements

Client / Responsible Party Signature

Sign Here

Date

Primary Caregiver / Staff Signature

Sign Here

Date

Supervisor / Administrator Signature

Sign Here

Date

Client Care Plan

Client Information

Emergency Contact Information

Health History and Medical Information

Current Medications (including dosage and frequency)

Client Preferences and Cultural Considerations

Assessment of Needs

Goals of Care

Planned Interventions and Services

Monitoring and Evaluation

Signatures and Acknowledgements

LINKS

Resources

INFORMATION

Areas we serve