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Service-Fit Inquiry

Structured Companion Support Intake

This short form helps determine whether CarePlanCompass™ Structured Companion Support Services may be the right fit before scheduling a visit.

Services are non-medical and do not include hands-on personal care, medication management, therapy, skilled nursing, transfer assistance, ambulation assistance, or ADL assistance.

Step 4

Service-Fit Screening Form

Family / Contact Information
Client Information
Requested Companion Support

Select all that apply.

Scope Screening

Answering “yes” does not automatically decline the inquiry, but it does require scope review before scheduling.

Does the client need help bathing?

Does the client need help dressing?

Does the client need help toileting?

Does the client need help grooming?

Does the client need help eating or feeding?

Does the client need help standing, walking, or transferring?

Does the client need medication administration or medication management?

Does the client need therapy, exercise supervision, nursing, or medical monitoring?

Does the family expect staff to follow a care plan or discharge plan?

Does the family expect staff to physically prevent falls?

Does the client need hands-on help entering or exiting a vehicle?

Can the client participate in companion visits without staff providing hands-on physical assistance?

Transportation / Accompaniment

Are you requesting appointment, errand, or community accompaniment?

Community accompaniment is non-assistive. Staff may accompany but may not provide physical help entering/exiting vehicles, curb support, balance support, transfer assistance, or medical transport.

Scope Acknowledgment
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