Individualized Care Plan Assessment -

By: 247 Care  09-12-2011

Individualized Care Plan (ICP)

   Please provide the following contact information:

First Name

Last Name

Street Address

Address (cont.)



Zip/Postal Code


Home Phone

Work Phone


Please help us serve you better by completing our Needs Assessment:

Check the days you/your family will be requiring Care/Support:
Monday  Tuesday  Wednesday  Thursday  Friday  Saturday  Sunday

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.


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


Morning Snack


Afternoon Snack


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:

Please contact me as soon as possible regarding this matter.
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