Full Application

Person Centered Service Plan

We want to know your full story. This comprehensive form helps us create a service plan that truly reflects who you are, what matters to you, and your goals. You can answer as much or as little as you're comfortable with—we'll explore the rest during your visit.

About you

First name *

Last name *

Date of birth

Phone *

Gender

Primary language

Race / Ethnicity

Marital status

Home address

Caregiver & family contact

The person we'll coordinate with about your care and service planning.

Caregiver name *

Caregiver phone *

Relationship to you

Your health history

This helps us understand your needs and provide the right support.

Primary physician

Physician phone

Medical conditions

Current medications

Allergies

Hospitalizations (past 2 years)

Recent surgeries

Cognitive status / Memory

Hearing & vision

Mobility aids

Dietary needs

Mental health history (if comfortable sharing)

Your story, your strengths

What makes you who you are? What brings you joy?

What are your personal strengths?

Daily living skills (cooking, self-care, etc.)

How do you like to communicate?

Hobbies & interests

Spirituality / faith traditions

Cultural background & preferences

Social preferences (large groups vs. one-on-one, etc.)

Community involvement / volunteer history

What you need help with

Areas where you need assistance

Any behavioral or emotional concerns?

Safety concerns (falling, wandering, etc.)

Needed environmental modifications

Your goals & desired outcomes

What do you hope to achieve? What activities interest you?

What are your primary goals?

What types of activities interest you?

Activity Categories (check what interests you)

Cultural activities

Educational activities

Physical activities

Social activities

Intellectual / cognitive activities

Insurance & legal information

Coverage type

Plan name

Member ID

Risk management & safeguards

Are you part of a vulnerable population? (homeless, abuse survivor, etc.)

Any history of or risk for abuse/neglect?

Financial or exploitation concerns?

What safeguards do you want in place?

Your rights

Review: Which rights are most important to you?

Are there any restrictions on your freedoms needed for safety?

If yes, why are they necessary?

What less restrictive alternatives have been considered?

Acknowledgement

Date of acknowledgement

Additional notes or comments

I confirm that the information above is accurate to the best of my knowledge, and I consent to The Way Social Senior Care contacting me about this application. I understand formal enrollment requires additional paperwork to be completed in person and that my service plan may be updated based on further assessment.

Find this overwhelming? Go back and choose Quick Apply instead.