Of course Coastal Care Nursing provides compassionate and professional private care. But the secret to our success – and many happy clients - is matchmaking. After all, caregiver/patient compatibility is key to a better, more comforting care experience. That’s why we focus on your personality, needs and preferences to make your perfect caregiver match. So you are comfortable and at ease with your caregiver from the moment that you join the Coastal Care family.

Just answer the following questions to make your match.

Section 1. General Information

 

Client Name:

 

Client Phone Number:

 

Your Name (if not the client):

 

Your Phone Number (if not the client):

 

Email:

 

How did you hear about us? Please select… Word of Mouth Online Coastal Care Nurse Newspaper/Magazine Mail Television Press (Article, News) Radio

 

Where does the client live? Please select… Englewood Fort Myers Lakewood Ranch Nokomis North Port Osprey Port Charlotte Punta Gorda Sarasota Venice

 

What type of caregiver are you looking for? Please select… Unsure Companion Certified Nursing Assistant Licensed Practical Nurse Registered Nurse

 

What is the client’s living status? Choose Option Lives alone Lives with spouse Lives with another

 

Section 2. Assessing Needs

 

What is the client’s level of family support? Choose Option Family lives in close proximity Family lives further than 25 miles Family lives out of state

 

What level of support are you interested in with Coastal Care? Choose Option Not sure Partial Support Full Support

 

Please list all medical conditions and concerns:

 

Describe any special family needs. (For example, dad does not want to admit to he needs help in his home. I would like to introduce him to the idea of care.):

 

Section 3. More Details

 

Describe the client’s previous occupation and education:

 

What are the client’s hobbies?

 

Specific topics of interests?

 

Characteristics that describe the client: (i.e. good listener, caring, outgoing, etc.)

 

Characteristics you feel are most important for your caregiver:

 

Caregiver Personality Preference: Choose Option No Preference Strong Medium Mild

 

Do you have a language preference?

Yes
No

 

If Yes, what language do you prefer?

 

Do you prefer a male or female caregiver? Choose Option No Preference A Female Caregiver A Male Caregiver

 

Do you have any preferences that were not previously mentioned that we should consider while choosing your match?

 

Please Verify (Type in the letters and numbers you see in the box):