Move Orientation Form

* = Required Information

Internal A Helping Hand Senior Care Services Move Orientation

Name *

Move Date:

From *

To *

By signing below, I am indicating that I have been oriented in the following areas and have had the opportunity to ask questions:

Advised of the right to review and have input to the company’s policies and procedures required by Comprehensive Home Care
Notified that the individual is responsible for replacement of any and all property owned by A Helping Hands Senior Care Services LLC that is intentionally damaged or destroyed by the admitting individual
Program Abuse Prevention Plan (PAPP)
Review of Emergency Procedures, including escape routes and
Emergency #’s (copy provided)
Smoking Policy, including locations where smoking is permitted

Requested copy of current/updated CSSP from Case Manager

Yes

Date Requested

Requested Via

Phone Request

In Person

Individual *

Date *