Negotiated Service Agreement Page 1 of 6
NEGOTIATED SERVICE AGREEMENT
Facility name: Date entered: ______Current date: ______
Client’s name: Date of birth: ______Age: _____ Language(s) spoken
Name of interested party (POA, guardian, or family): Phone (H): (W):
Address of person listed above:
Physician’s name: Phone #:
Advanced directive/Living will/Legal Documents yes no Type: ______
Medical History: / Current Medical Status:Dressing
Indep Assist Depend
Day time wishes:
Nighttime wishes: /
What client prefers to do independently
/What provider/support person does/When
Personal Hygiene
Indep Assist Depend
How often?
When?
Time required:
Preferences:
Bathing
Indep Assist Depend
How often?
When?
Time/equipment needed:
Preferences: /
What client prefers to do independently
/What provider/support person does/When
Eating
Indep Assist Depend
Special diet?
Eating habits:
Food allergies:
Equipment needed:
Wishes:
Toileting
Indep Assist Depend
Urinary problems?
BM control?
Needed equipment:
Wishes:
Mobility/Transfers
Indep Assist Depend
Adaptive equipment?
Extra transporting support?
Preferences: /
What client prefers to do independently
/What provider/support person does/When
Positioning
Indep Assist Depend
Equipment/supplies?
Preferences:
Communication/Visual
Visual problems: yes noHearing problems: yes no
Able to express self: yes no
Comments:
Medication
Indep Assist Administer
Schedule:
Allergies:
Preferences:
Pleasurable Activities
Indep Indvidual Group
Preferences: /
What client prefers to do independently
/What provider/support person does/When
Nursing Services
Yes No / DESCRIBE NURSING SERVICES PROVIDED: / DESCRIBE NURSE DELEGATED TASKS:
Behavioral Issues
Yes No
Describe:
Leaving the Home
Can client leave home independently?
Yes No
If no, describe methods to maintain safety:
Health issues to monitor:
Volunteer services provided/when:
Contractors utilized/services/when:
Physical enablers:
NOTES:
SIGNATURE PAGE – NEGOTIATED SERVICE AGREEMENT
Date of original plan:
Signatures:
Provider/Owner: / Date: / Review Date: / Review Date:Client: / Date: / Review Date: / Review Date:
Client Representative: / Date: / Review Date: / Review Date:
Client Representative: / Date: / Review Date: / Review Date:
Caregiver: / Date: / Review Date: / Review Date:
Health Professional (if applicable): / Date: / Review Date: / Review Date:
Case Manager (if applicable): / Date: / Review Date: / Review Date:
Other Participant: / Date: / Review Date: / Review Date:
INFORMATION WITHIN THIS DOCUMENT IS CONSISTENT WITH REQUIREMENTS IN WAC 388-78A
Client Name: