Assessment Interview / Notes /Care Plan Development     Date:  	

Client Name:  ________________________________	      Client ID: 	
Client Age:  _________________________________       Client Age:  	

Question and Task Bank:

Situation (Dx, current treatment, recommended treatment) 		

Prognosis 		

Wishlist (what does your client hope you can do?) 	

Expectations (what does your client expect that is possible to accomplish?) 	

Insurance challenges / constraints 	

Timeline (if applicable – any deadlines, wait times, etc) 	

Additional:  (imaging, drugs and supplements, medical records retrieval, appointments, transportation, communication with family, prescription reviews, check-ins, home safety checks, others)  	

Providers and Contact Info: 	

	

Pharmacy (plus location and phone) 	
	
Insurance Details (Primary, Secondary): 	

Other Specifics: 	

Use additional pages for more notes and information.
 
Possible Add-On Services:
Prescription Review
Home Safety Review
Collection / Development of Advance Directives
Insurance Review (finding better plans)
Records Binder / Organization (include out of pocket cost for binder and dividers)
Medical Bill Review / Organization

Service Required	Estimated Time Required	
		
Medical Records – Collection time		
Phone calls 		
Appointment time 		
Care Coordination / Finding Providers		
Transportation		
Follow up, reporting, recording, misc needs		
Prescription Review		
Medical Bill Organization		
		
TOTAL Time Estimated		

(none of these hours include out-of-pocket expenses)

Hourly rate:  ________________

Math:   (time x rate)

Total for this project:  ___________________________  (transfer this to the estimate)