Opening Hours
Mon _ Fri: 7.00 AM to 10.00 PM. Mon _ Sat 9:00 AM to 9:00 PM
Contact
tony@betterdaysadc.com
Drop A Line
(360) 232-2348
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Personal Information
Full Name
*
Date of Birth
Gender
*
Male
Female
Other
Address
Phone Number
Email Address
*
Emergency Contact
Name
Relationship
Phone Number
Alternate Phone
Medical Information
Primary Physician
Phone Number
Medical Conditions (e.g., diabetes, dementia)
Allergies
None
Yes – Please list
Functional Status
Mobility
Independent
Uses Cane/Walker
Wheelchair
Needs Assistance
Toileting
Independent
Needs Assistance
Incontinent
Feeding
Independent
Needs Assistance
Tube Feeding
Social and Behavioral Information
Preferred Activities
Arts & Crafts
Music
Games
Exercise
Other
Behavioral Concerns
None
Wandering
Aggression
Other
Transportation Needs
Will the client require transportation?
Yes
No
Pick-up Address (if different)
Insurance and Payment
Insurance Provider
Policy Number
HTML
Responsible Party for Payment
Name
Phone
I certify that the information provided is accurate to the best of my knowledge.
Pricing
Daily Rate
Weekly Rate
Monthly Rate
Full Day (6–8 hours): $85 Per Day
Half Day (up to 4 hours): $55 Per Day
Full Week (5 Full Days): $400
Half Days (5 Half Days): $250
Full Month (20 Full Days): $1,500
Half Days (20 Half Days): $950
Payment
Daily Rate
Total Daily Rate
Weekly Rate
Weekly Rate
Total Weekly Rate
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