Personal Care Guardianships Inc.

GLORIA COSTANTINO MBA

6278 N. Federal Hwy #230
Fort Lauderdale, Florida 33308
Phone: (954) 610-9621
Fax: (954) 229-7095
email: gloria@personalcareguardianships.com

CONTACT INFORMATION

Your Name:	Phone Number:
Email:	Best Time to Contact:
Relationship to Client:

Client Information: Fill out to the best of your ability

Prospective Client's Name:	Age/DOB:
Sex: Male Female	Address:
Current living arrangements:
Advanced directives: Living will Medical Surrogate Power of Attorney Trust Will
Any previous Military Service? Which branch, date of discharge (if spouse was veteran, copy of marriage certificate, discharge papers).
Long Term Care Insurance:

DIAGNOSIS

Alzheimer’s
Aphasia
Congestive Heart Failure
Depression
Dementia

Developmental Disabilities
Diabetes
Emphysema
Heart Disease
Mental Illness

Multiple Sclerosis
Parkinson’s
Stroke
TIA’s
Other:

Type of Assistance Needed

Bathing
Caretakers-hiring/screening and supervision of home health aides/CAN/LPN/RN
Care Managements-Oversee and coordinate all clients needs
Computer assistance-help set up Web Cams/email/online services so you can stay connected
to family and friends
Companionship
Dressing
Feeding/Meal Preparation
Financial Management-banking, bill pay, bookkeeping and assistance application
of Medicare-Medicaid and VA benefits
Home care-maintenance and repair of clients home, hiring and supervision of repairman
Housekeeping
Incontinence
Laundry
Medication Management
Moving/Relocation Service-find the appropriate living arrangement and assist
with entire process for a smooth transition
Rehabilitation Assistance from injury or surgery
Shopping for supplies/groceries
Transportation to Shopping and Doctors appointments

Type of Service Requested

Care Managers
CNA-Nurse
Companion
Financial Assistant/Bookkeeper/Accountant
Guardian

Home Health Aide
Live-In
POA
Trustee
Unknown, need assessment

QUESTIONS OR COMMENTS