24-Page Home Care Client Assessment Template

Start every new client relationship with a clearer picture of the person and the support they need.

Created by Danielle, an experienced non-medical home care business owner, not AI. This practical, editable assessment helps your agency gather client information in one organized place before services begin.

Get a detailed 24-page Microsoft Word (.DOCX) home care client assessment, including the cover page. Use it as a starting point for your intake and service-planning process, then tailor the questions and branding to your agency.

What the assessment helps you document

• Client, family, authorized representative and emergency contact information
• Living situation, communication, routines, preferences and social activities
• Assistance needs with personal care, meals, mobility, transfers and household tasks
• Home safety, accessibility, equipment and fall-risk considerations
• Medication reminders and medical or emergency information provided by the client or family
• Consent, transportation needs and signature areas

Many daily-living sections include selections for no assistance, some assistance or full assistance, with room to record additional details. The result is a more consistent way to capture what a client can do independently, where support may be needed, and what caregivers should know about the client’s preferences.

What you’ll receive

• One editable Microsoft Word document (.DOCX)
• 24 pages total, including a cover page with space for your agency name, address and logo
• A digital product; no physical item will be shipped

Edit the wording, add or remove sections, and adapt the form to your agency’s process. Creating a detailed assessment from scratch takes time; this template gives you an organized foundation to customize.

Designed for non-medical home care

Suitable as a customizable administrative tool for non-medical home care, personal care, companion care and private-pay agencies. It is not a clinical assessment and does not replace evaluations or documentation required from a licensed healthcare professional. Requirements vary, so review and adapt the template for your agency’s services and applicable rules. The purchaser is responsible for determining whether additional documentation is needed.

Build out your agency toolkit

Need more than an assessment form? Explore the Complete Home Care Business Bundle and other Wise Caregiving resources.

Customize it. Brand it. Make it your agency’s own.

© Wise Caregiving®. For purchaser use only. Do not resell, share or redistribute the template.