How Can we help?
Registration For New Clients
This form provides the details of our new clients so we can best match them to our companions.
Your Relationships With Client (please select all that apply)
I am the Client needing service
Power of Attorney
Emergency Contact Phone
Do Not Resuscitate
Do Not Intubate
Polst Location, Info and Phone
How did you learn about us?
Already Using our Services
Word of Mouth
How Did you Hear about us? Please write in answer
I agree to our privacy and marketing policy.
The information we gather is to understand yours and your client's needs to provide you with a better service, and in particular for the following reasons:
Email Communications for outings and billing.
Email Communications for discounts, upcoming events, marketing and reminders.
You can opt out at any time from our marketing and event newsletters by using the checkbox in the body of the email, or by emailing me directly at email@example.com
Yes, only for internal use and reporting
Yes, for both reporting and marketing
No/Please contact me
I hereby grant permission to Companion Life Services to use photographs and/or videos taken by company representatives of the client (named above) in publications, news releases, online, and in other communications related to the work and mission of Companion Life Services
Is the client a Veteran?
We offer an immediate discount to all of our Veterans. Please call Terry at 503-748-9464 for details.
Client's Personal Cell or Room Phone
Date of Birth
Date Format: MM slash DD slash YYYY
Name of Home or Facility
Home or Facility Phone
Primary Contact at Home or Facility
Primary Contact Role or Position?
Please do not abbreviate, we don't always know what those abbreviations mean.
Home or Facility Address
apt or room #
State / Province / Region
ZIP / Postal Code
Additional Contacts at the Home
Please provide any additional contacts at the home or facility that is familiar with the client. This info is for scheduling and client communication. Please provide any additional phone numbers contacts at the home
Client Photo or ID
Please upload a newer photo or current client ID
Client Insurance Card to have on File
Good, No Glasses
Good, no issues communicating
Fair, some issues communicating
Bad, many issues communicating
Written communication necessary
Ambulatory needs help transferring
Manual Wheel Chair. Can Transfer to Car
Manual Wheel Chair, can not transfer
Motorized Wheel Chair
Please describe any and all limitations they need assistance with. Some of our companions are not able to help with transferring from wheelchair to vehicle.
Please describe bathroom needs, how long they can be out without bathroom help. Briefs, colostomy bag, any other special needs? We do have some companions that will assist as needed, that is why it is important to be as complete as possible to find the right match for the client and caregiver.
Mental, Medical histories, Medical Allergies
Rules and Restrictions Please give guidelines regarding; caffeine, alcohol, cigarettes, marijuana. (none, or max quantity if yes, guidelines if yes to any of these items.)
Please give guidelines regarding; caffeine, alcohol, cigarettes, marijuana. (none, or max quantity if yes, guidelines if yes to any of these items.)
Interests, Likes and Dislikes
Outing Types of Interest (choose all that apply)
Travel, Vacations in and out of state
Outing Goals and Needs
shopping, hair cuts, dining out, special events, medical only, help moving...
1 x Month
2 x Month
3 x Month
2 x Weekly
3 x Weekly
4 x Weekly
These can always change, we are flexible, we have no minimums.
Conversation Topics, Likes and dislikes
Marital Status, Children, Grandchildren, Siblings, Parents, Past hobbies, occupation, religion, education...
Desired Outing Length
1-2 hours max
2-3 hours max
3-4 hours max
5-8 hours max
Due to the nature of our business and the size of our work area, we try to maximize the time spent with the client and not drive time. That being said, drive time does factor into the outing time. The hourly rate includes the first 50 miles per outing. Beyond 50 Miles we charge $1.10 per miles. We do offer discounts for our Vets and travel packages. Call for quotes 504-498-8800
Outing Expenses Paid By
Cash will be provided
Credit card will be provided
Companion Life Services Credit
Maximum Outing Budget per Outing
Dining, Meals Allowance for Companion
Our companions are often in a situation where they may be dining with the client. They are hourly employees, an employee allowance is recommended for these social outings. If they are attending an event or there is a cover charge, these costs will be charged to the client. There are many locations that allow companions free entry, if you have any questions or need clarity please call, 503-748-9464
Any other information, questions or ideas you may have?
This field is for validation purposes and should be left unchanged.
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10175 SW Barbur Blvd, Ste 206B Portland, OR 97219
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