FH-CL-002 • VERSION 1.0

Client Service Plan

Authorized services, goals, routines, safety instructions and limits.

Digital workflow: Complete required fields, review carefully, then submit. A submitted record is timestamped and preserved for office review.

1. Record identification

Client name *

Date *

Completed by *

Plan effective date

Review date

Primary and independence goals

Days, times and weekly hours

Mobility, devices and fall instructions

Medication reminder method and limits

Transportation / outing limits

Errands / funds limits

Home access and household considerations

What caregivers should observe and report

Client-specific instructions

Electronic signature / typed name *

Signature date *

Notes