Senior Impact

My Own Case Management/Coningency Plan

List family, friends and/or agencies who help with these tasks, or could help in an emergency.

Meal preparation/shopping or home-delivered meals:

Name ______________________________________ Phone __________________________
Name ______________________________________ Phone __________________________

Routine housework/laundry:

Name ______________________________________ Phone __________________________
Name ______________________________________ Phone __________________________

Administer finances:

Name ______________________________________ Phone __________________________
Name ______________________________________ Phone __________________________

Home health care (including giving medication):

Name ______________________________________ Phone __________________________
Name ______________________________________ Phone __________________________

Transportation:

Name ______________________________________ Phone __________________________
Name ______________________________________ Phone __________________________

Feeding:

Name ______________________________________ Phone __________________________
Name ______________________________________ Phone __________________________

Bathing/dressing/grooming/toileting:

Name ______________________________________ Phone __________________________
Name ______________________________________ Phone __________________________

Care coordination/arranging for services (friendly visitor, telephone reassurance):

Name ______________________________________ Phone __________________________
Name ______________________________________ Phone __________________________

Additional family, friends, agencies, church members, pastors, etc., that could be contacted for emergency help:

Name ______________________________________ Phone __________________________
Name ______________________________________ Phone __________________________
Name ______________________________________ Phone __________________________
Name ______________________________________ Phone __________________________
Name ______________________________________ Phone __________________________
Name ______________________________________ Phone __________________________
Name ______________________________________ Phone __________________________