Support Planning Form This is the first set of questions we ask a potential new customer for RSC Step 1 of 4 25% Your Name (Caretaker)(Required) First Last PhoneYour Zip Code ZIP / Postal Code Email(Required) Loved one's NameRelation to Caretaker Mom Dad Other Their Zip Code ZIP / Postal Code Their AgeTheir GenderMaleFemaleIs there a second person living there? Yes No If so, what is the relation to primary resident? Rate their mobility (1-10) 1 being very limited & 10 being excellent mobility(Required)12345678910Please SelectRate their hearing (1-10)(Required)12345678910Please selectGeneral health & mental summary: Tell us about their general situation in just a sentence or 2.Morning pills? Please check one Yes No Evening pills? Please check one Yes No Medication: Would it be helpful to have a pill dispenser that automatically dispenses the right pills once or twice a day that only need refilling once or twice per month? Yes No Maybe Are there regular visiting care practitioners? Never Set Days/Week Daily Full TIme Interaction: Would it be helpful for your loved one to get friendly automated custom greetings throughout the day with their name, the date, some weather, and possibly their appointments for the day? Yes No Maybe TV: Would you benefit from a TV that could be controlled remotely & automated for on, off, volume & channel setting? Yes No Maybe Queues: Would it be helpful to have a screen that could queue your loved-one about meal times, bedtime and other customized helpful queues? Yes No Maybe Are there currently Amazon Alexa devices in either home? I have I don't have They have They don't have Do they currently have a security system or cameras? Yes No If you have cameras, what area(s) do you monitor and what service do you use, if any?Rate the internet speed and reliability at your loved ones house as far as you know. Slow Moderate Fast Please add any (optional) additional comments here.
