Portfolio Submission Form

1
Name of Purchaser
First Name
Last Name
2
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
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Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
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El Salvador
Equatorial Guinea
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Ethiopia
Falkland Islands
Faroe Islands
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France
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Gabon
The Gambia
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Guinea
Guinea-Bissau
Guyana
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Hungary
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Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
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Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
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Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
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Turks and Caicos Islands
Tuvalu
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United States
Uruguay
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Vanuatu
Vatican City
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Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
3
Email
example@example.com
4
Phone Number
Please enter a valid phone number.
5
Preferred Method of Contact Please Choice your best method of contact.
No Preference
Text
Email
Phone Call
6
Guidebook Information* This field is required.For Whom does this Guidebook Represent?
First Name
Last Name
7
Cover PhotoPlease upload a picture for the cover of the Guidebook.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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8
FamilyTell us about your family. Where does this person live? Who lives with them? Examples of Family traditions, family stories, what is important to this person?
Whom does your child live with; family members or pets?
Are there any special traditions that are important to your family
Anything else you think is important about your family life?
9
Family PhotoFeel free to upload a family photo
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Max. file size: 10.6MB
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10
My StoryTell us about this person, are they shy or outgoing. What is the nature that prompted this Guidebook? Do they prefer to be independent or will they except help? What are their strengths or weaknesses? What do they value most?
11
Emergency Contact Information
First Name
Last Name
12
Emergency Contact Email
example@example.com
13
Emergency Contact Phone Number
Please enter a valid phone number.
14
Preferred Method of Contact for Emergency Contact
Please Select
Please Select
Call
Text
Email
15
Emergency Contact #2Please type the information for the Backup Emergency Contact
Name, Email, Phone and preferred method of contact.
16
LikesTell us about their favorite things, can be food, toy, prize possession. What do they love doing? What is their favorite activity, sport, movie, or book?
17
Photos of Favorite ThingsFeel free to upload pictures of their favorite toys or items.
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Select files to upload
Max. file size: 10.6MB
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18
DislikesWhat sets them off, what is an absolute No? Do they not like vegetables, or to be touched?
19
Medical AlertsDoes this person have a medical condition? What should people do in case of an emergency? Do they have allergies, should they avoid a specific food or animal?
20
Activities PhotosPlease upload some pictures for us to include in this portfolio. Maybe something that makes them happy? A picture of their favorite thing to do or them with a favorite person.
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Select files to upload
Max. file size: 10.6MB
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21
CommunicationHow do they communicate, are there challenges? Do they use an alternative communication method? Are they bilingual? Will they ask for what they need or want?
22
Behavior or Special CareAre there any special challenges with behavior or moods? Do they work better at a certain time of day? Are they affected by “Sundowners”? What calms them down? What should people around them avoid at all cost? Is there something that should be avoided at all cost? Is there a special item in the house, special toy or memento that is especially important to them?
23
Personal CareAre they independent or need help with personal hygiene? Help with bathing, dressing or toileting? Do they need a visual schedule? Do they need constant reminders or assistance? Do they need a visual instruction sheet on washing hands or taking a bath?
24
Special Request
25
FeedbackWould you like to include feedback from past caregivers? Would you like a survey form for current caregivers for feedback to include with your next update?
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Max. file size: 10.6MB
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26
SubmissionThis does not replace your physician’s medical record(s). This is intended to be a helpful tool for personal purposes only. By filling out this online form and submitting, you are agreeing to our HIPAA policies and procedures and release “Our Little Peace of Mind, Inc.” from any liability related to this information.
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