--000000000000fb0f8e0647fbfc96 Content-Type: text/plain; charset="UTF-8" Commitment Client Yes or NO : No Client consent paperwork uploaded - Yes OT approved- NO HCL: Micah Office Milwaukee Regional Intake Manager: Emily L Caregiver Manager: Pat Client Success Manager: Ashley Referral Source: Care scout *Client Name:* Herman Langford *Client Address:* 8901 N 70th St, Milwaukee, WI Gated Community/Code/Parking Instructions: Home Phone: *Contact Person:* POC Montez # (414) 324-4784 Assessment Completed on: 12/5/2025 *Schedule:* Mon, Wed, Fri 10am- 2pm *NO Care the week of Feb3- Feb 8th. CL will be in Houston TX for all of July- August. They would like services transferred out of state during this time.* *Start Date:* 1/22/2026 Bill Rate: Private pay rate $36 CL has elimination period with LTCH John Hancock- CareScout Rate Quoted 38.75 Client Narrative: *Care Match - CPE = C3; P2; E3-*Mr. Herman is a retired history teacher who lives with his daughter Montez and her husband Wayne. Montez would like to utilize Mr. Herman's John Hancock policy for LTCI, for an in-home caregiver. S Mr. Herman would benefit from companionship care; and someone who can motivate him to stay active. Ht:5'9 Wt: 175 Gender: Male Routine/Tasks Mr. Herman will benefit from SBA with walking & transferring, he doesn't use any assisted devices at this time. He will require HOA with (showering, meal prep/ serving) and is able to dress himself & complete many personal cares with verbal cueing/ reminders. Montez obtained a YMCA gym membership for Mr. Herman & would like the CG to transport and chaperone him- he may have a personal trainer/ join a class at the facility. She is very interested in our BCM- and keeping him engaged. We discussed our CG activity bags with activities for cognitive and creative stimulation and she was impressed. She says she has a few items at the home for cognition like games but would love a proactive self starting CG who can motivate him. She will be purchasing coloring books and craft items to keep him engaged. Montez worries about Mr. Herman being up in his room all the time & is looking forward to an enthusiastic CG to motivate him and keep him from being so withdrawn. *DL:* Yes *Car: *Yes *Cg preference*: Enthusiastic, high energy with the ability to use redirection techniques. Someone who is not afraid to hear NO and try again; A caregiver with solutions and ideas to keep him stimulated, and engaged during the shift. Cats: NO *Dogs/Breed:* Yes- kept in Kennel Smoking: NO -- -- *Ashley Alford* CSM/ Caregiver Manager | TheKey Mobile: 414-704-3806 --000000000000fb0f8e0647fbfc96 Content-Type: text/html; charset="UTF-8" Content-Transfer-Encoding: quoted-printable Commitment Client=C2=A0 Yes or NO : No=C2=A0 Client consent paperwork uploaded=C2=A0 - Yes=C2=A0 <span= style=3D"font-size:11pt;color:rgb(0,0,0);background-color:transparent;font= -variant-numeric:normal;font-variant-east-asian:normal;font-variant-alterna= tes:norma