Client Assessment Forms GENERAL INFORMATION & EMERGENCY CONTACT LIST What Amicable Healthcare location will you be receiving service from? * Seatac (King County) Tacoma (Pierce County) Everett (Snohomish County) Client Information Client Name (First, MI, Last) * Client Phone Number * Today's Date * Client Address * Client Address Address Line 1 Address Line 1 Address Line 2 Address Line 2 City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Physician Information Physician Name * Physician Phone * Physician Address / Location Emergency Contacts 1. Nearest Relative Name * Phone * Relationship to Client * 2. Friend / Relative Name Phone Relationship to Client Other Important Information Resuscitate Orders in the Home * Yes No Resuscitate: To revive or restore someone who is unconscious, or apparent death Special Instructions in Case Of Emergency: * Call 911 Hospital Code Status: This form must be posted in a visible place at the client’s home and easily accessible via the client file in the office in case of emergency arises. Client or Authorizing Representative’s Signature * Clear Today's Date * If you are human, leave this field blank. Next