Client Forms

You can either download the following forms or open them and print on your printer. You will need Adober Acrobat to view the PDF files. To download to your computer, right click and choose "Save As". To open and print, double click. Files will open in a separate window.

CLIENT PRE-SERVICE PACKET - All Families must complete within 10 days of start of service and must revise as information changes

Client Pre-Service Packet (PDF File)

Included in above Client Pre-Service Packet are the following forms:

• Client Pre-Service Information
• Client Emergency Contact Information
• Payroll Agreement
• Release of Information
• Transportation Release-Client
• Emergency Contact Plan
• Medical Treatment Authorization Form
• Administration of Medications Authorization Form

TIME SHEETS:

Habilitation Time Sheet (PDF File)

Respite Time Sheet (PDF File)

Attendant Care Time Sheet (PDF File)

Housekeeping Time Sheet (PDF File)

Paid Sick Time Time Sheet (PDF File)

PROGRESS REPORTS:

• Habilitation Progress Report (PDF File)
  • Guide on how to full out Habilitation Progress Reports (PDF File)
    • Sample of completed Habilitation Progress Report (PDF File)

• Attendant Care Report(2 page) (PDF File)
  • Sample of completed Attendant Care Progress Report (PDF File-2 pages)
    
    
• Medication Log - Must be completed if Employee Administers Medications during month to Client (PDF File)

INCIDENT REPORT - All Incidents must be reported within 24 hours to Affinity Family Care Office

• Incident Report (PDF File)
  • Guide to types of incidents that should be reported.  It is mandatory all employees report incidents within 24 hours to Affinity Family Care 

CHANGE OF INFORMATION FORM (Direct Deposit/Name/Address/Phone Number etc.)

Change of Information - address/telephone, etc. (PDF File)

EMPLOYMENT APPLICATION:

Employment Application - 2 page (PDF File)

TAX FORMS:

2020 - A-4 – Arizona State Tax Withholding (PDF File)

2020 - W-4 - Federal Tax Withholding (PDF File)

I-9 Form - Employment Eligibility Form (PDF File)

TRANSPORTATION RELEASES:
NOTE:  Employees may only transport in their private vehicles.  Employees MAY NOT transport in client/family vehicles without expressed permission from Affinity Family Care

• Transportation Release Form - Client/Family ( PDF File)
• Transportation Release Form - Employee (PDF File)
• Transportation Release Form - Full (used when employees not transporting client (PDF File)

MISCELLANEOUS FORMS:

Client Photography/Video/Stories/Other Release– (PDF File)

Grievance Complaint Form (PDF FILE)

Behavioral Assessment (PDF Doc)

Criminal Record Disclosure Form (PDF Doc)