Our plan for support at home.
A practical record for the family conversation, provider calls and the next check-in.
Print this page or choose “Save as PDF” in your browser's print dialog. Write by hand or keep answers in your own private notes. This page does not collect or save worksheet answers. Keep medical records, passwords and entry codes elsewhere. Read the companion guide for context; this is not a medical or housing assessment.
1. The person and the priority
Date and people taking part:
What I want to keep doing, in my own words:
One task that has become harder; what we actually noticed:
Help I welcome, and things I do not want monitored or changed:
First step without buying anything: A routine change, existing feature, clearer route or a conversation with someone who can help.
2. People, support and follow-through
Question for a clinician, pharmacist or occupational therapist: Who will arrange the conversation, and by when? Keep symptom notes and medication lists separately for the healthcare appointment.
Primary helper and realistic availability: Include what they can and cannot commit to.
Backup when that helper is unavailable:
Our agreed check-in and missed-check-in procedure: Who acts, when, and how?
Support to investigate locally: Transport, meals, home help or respite. Try eldercare.acl.gov in the US.
For an immediate emergency, call 911 in the US. A scheduled family check-in is not an emergency response service.
3. Compare two suitable options
Skip this section if you are not considering a product. For an alert decision, include an existing-phone approach if appropriate. Write “unknown” instead of guessing, and keep the provider's written terms with your receipt. You do not need to buy anything to complete a useful plan.
Exact model, provider and quote date
Write the exact plan and equipment, not just the brand.
Where it must work
Home rooms, bathroom, garden and usual destinations; confirm connection and range.
How help is requested
Manual button, approved wearing position, optional detection and what can be missed.
Who responds and what happens next
Monitoring service or family; cannot-speak procedure, backup contacts and home access.
Can the person use it?
Comfort, vision, hearing, dexterity, understanding, willingness to wear it and ability to summon help.
Power and upkeep
Charging frequency, charging gaps, battery/power backup and a named helper.
Complete first-year and renewal cost
Equipment + setup + shipping + monitoring + selected add-ons + required connectivity + tax. Record billing cadence.
Trial, returns and cancellation
When the trial starts, last return date, fees, equipment return, auto-renewal and prepaid refund rules.
Privacy and control
Who sees location or activity, what permission is needed, and how access is withdrawn.
Decision-critical unknowns
What still needs a written answer? Who will ask, and by when?
Use our product comparison to identify candidates and our cost calculator for your own verified quotes. This worksheet does not certify a product's effectiveness.
4. Agree on the action and the review
Our next action, person responsible and date: This may be a support arrangement, healthcare appointment or home change instead of a product trial.
The checklist below is only for a product trial. For other changes, record what a useful result would look like and when you will review it.
Use the provider's approved testing procedure. Do not stage a fall or make a test emergency call without provider instructions.
- □ The wearer can comfortably operate it and explain how to request help.
- □ Connection tested in agreed locations using the provider's test process.
- □ Charging, backup and any wearing restrictions understood.
- □ Response procedure, contacts and approved home access checked.
- □ All charges, return conditions and cancellation instructions recorded.
- □ The person wants to keep using it.
What did not work, or still needs an answer?
Review date / return deadline / person responsible: Leave time before the return window closes.
Keep, adjust, return or seek more support—and why:
What change would make us revisit this plan? Think about unmet daily needs, repeated difficulty getting help, caregiver capacity or a change in the person's wishes.