Tell us about the person we will be caring for

Name: Westlake Family Home Care
Address: 2219 York Rd Ste 27, Timonium, MD, 21093, US
Telephone: 443-645-4022

Complete this paperwork at your own pace, from any device. Your care manager will use it to prepare a personalized care plan before your in-home assessment.

Your answers go only to our care team. To send an insurance card or medical records, use the Patient Portal.

Person Receiving Care

Full Name

Date of Birth

Phone

Preferred Language

Home Address Where Care Is Provided

Family Contact Completing This Form

Your Name

Relationship to Care Recipient

Phone

Emergency Contact

Name

Relationship

Phone

Care Needs

Services of Interest

Nursing ServicesPrivate Duty CareDementia CarePersonal CareRespite CareCompanion CareMedical TransportationIn-Home Therapy (PT, OT, Speech)

Health Conditions or Diagnoses

Medications and Allergies

Mobility

Preferred Start Date

Days and Hours of Care Needed

Home Notes (pets, stairs, parking, anything caregivers should know)

Physician and Payment

Primary Physician

Physician Phone

How Will Care Be Paid For?

Insurance Company (if any)

Please do not enter Social Security numbers or policy numbers here. Upload insurance cards through the Patient Portal.

Consent and Signature

I agree that WestLake Family Homecare may contact me to schedule an in-home care assessment using the information above.I confirm this information is accurate to the best of my knowledge and I am authorized to share it for the person receiving care.

Electronic Signature (type your full name)

WestLake Family Homecare

Maryland Residential Service Agency

RSA-02724

Exceptional Care. A Personal Touch. The Comfort of Home.

Company

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Careers

Reach Us

443-645-4022
info@westlakefamily.com
Fax: 443-645-4028
2219 York Rd, Suite 27Timonium, MD 21093

WestLake Family Homecare keeps every client conversation private and confidential, and provides services without discrimination on the basis of race, color, religion, national origin, age, sex, disability, or source of payment.