Getting To know You

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Our Mission

At Bloom Homecare, our mission is to deliver compassionate, dignified, and personalized care that supports the independence and well-being of every client we serve. We strive to make every home feel like a place of comfort, respect, and trust.

Our Vision for This Form

This form is more than just a questionnaire—it’s the beginning of a meaningful relationship. By understanding your background, preferences, and personality, we empower our caregivers to deliver care that is not just helpful, but heartfelt. Every answer helps us match you with the most compatible caregivers and ensures your care plan reflects your unique needs and lifestyle.

Purpose of the "Getting to Know You" Form

Build a personalized care experience tailored to you
Foster trust and understanding between you and your caregiver
Encourage meaningful connection and conversation
Ensure comfort, safety, and consistency in the services you receive

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Comments

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Please Fill Out the Following Questions

Clients Name*

First Last

Phone

Email*

What is your full name and what do you prefer to be called?

Where were you born and raised?

What languages do you speak?

Do you have any military or service background?

Are you interested to learn more about our Veteran Home Care Benefits?

What was your career or occupation?

Daily Preferences

What time do you usually wake up and go to bed?

Do you have a morning or evening routine you enjoy?

What is your preferred meal schedule?

What foods do you love and dislike?

Do you prefer a quiet or social atmosphere at home?

Hobbies & Interests

What are your favorite hobbies or pastimes?

Do you enjoy reading, puzzles, games, or crafts?

Do you have a favorite TV show, movie, or music artist?

Do you enjoy being outside? Any favorite activities (e.g., walking, gardening)?

Do you enjoy talking with others, or do you prefer quiet time? Comment

Social & Family

Who are the important people in your life you'd like us to know about?

Do you have any pets? Would you like your caregiver to interact with them?

Do you enjoy phone calls or video chats with family?

Is there a story or memory you love to share?

Comfort & Care Preferences

Are you interested to learn more about a visiting doctor traveling to your home?

Would you like to learn more about our Medical Home Health Care service covered by Insurance. We have traveling Nurse, Therapists and Social Workers?

Would you like a consultation with our Dieticians?

What helps you feel safe and comfortable?

Do you have any fears or triggers we should be mindful of?

Are there cultural or spiritual practices important to you?

Do you prefer a caregiver who talks and engages, or one who is quietly supportive?

Are there any activities you'd like to continue with the help of your caregiver?

Additional Notes

Is there anything else you’d like your caregiver to know?

Would you like us to share a short summary of this with all caregivers who visit?