Contact us – Everlasting Growth Private Care

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Phone Number

678-974-9000

Email Address

info@elgprivatecare.com

Fax

678-261-1854

Service Plan

Name of Client

Date of Birth

Address

Diagnosis

Client’s Functional Limitations

Types of Services Required

Nutritional Needs

Allergies

Services

Companion/Sitter Personal Care Assistant Nursing

Times of services

Frequency of Services

Duration of services

Describe how specific tasks are to be provided

Service starts on

Date

Regular Diet

Special Diet

Special Treatments

DME/SpecialEquipment

Tub bath

Bed bath

Applying lotion to back

Behaviors that may interfere with delivering service

Goals and Objectives

Medications

Discharge Summary

Date of first Review

Supervisor Signature/Date

Client’s name/Responsible Party

Signature/Date