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Client Intake Form

To help us provide the best possible care, please take a moment to complete the Client Intake Form below. Your answers give us the important details we need to understand your needs and create a personalized care plan. Thank you for taking the time—your information helps us serve you better.

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Participant Name *

Date of Birth *

Address *

Phone (Home) *

Phone (Cell)

Email *

Referred by

Supports Coordinator Name & Phone #

Reason for Referral *

Living Situation *

If "With Other", please specify

Proposed Funding *

MCO
Private Pay

Proposed Start Date *

Number of Hours Per Day *

Proposed Days of Week *

Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Notes on Proposed Schedule

Special Instructions/Requests

Preferred Caregiver Gender

Physician's Name *

Physician's Phone Number *

Physician's Fax Number

Other Physician

Primary Diagnosis *

Are you in pain? *

YES
NO

Level of pain

Location(s) of pain

Medications/Allergies *

Surgeries/Hospitalizations in the last year

Infections/Wounds? *

YES
NO

If yes, location on the body

Behavioral Needs: Aggression and/or Combativeness? *

YES
NO

H/O Verbal Inappropriateness? *

YES
NO

Wanders? *

YES
NO

Please check all that apply:

Toileting Independence
Wears Adult Undergarments
Catheter/Ostomy
Uses Oxygen
Smoker
Dizziness/Loss of Balance
Fall Risk
Hearing Problems
Vision Problems
Dentures
Uses Mobility Devices
Needs Ambulation Assistance
Dietary: Needs Assistance

If smoker, how often?

location Phone Date

If uses mobility devices, please specify:

Wheelchair (W/C)
Cane
Walker

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