Intake Application For New Clients

Point of Contact

Relationship to Client*

Parent / GuardianFamilyFriendOther

Mobile*

Telephone (2)

Emergency Contact*

Emergency Number*

Clients Name*

Client Birthdate*

Date

Gender*

Height*

Weight*

approximate weight

Race

Service Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please note any animals or other situations

Please Upload Insurance Front Image*

Please Upload Insurance Back Image*

Type Of Insurance*

Insurance Group#

Insurance ID#

Insurance Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Case Manager

Case Management Phone Number

Please enter a valid phone number.

Estimated Start of Care Date

Date

Preference of Caregiver: Male or Female

Please list required Services and equipment requirements

Service Required Days - Select all that apply

Total Hours Available

Please list any Important Health History

This agreement is entered into by Compassionate Healthcare Nursing Services (referred to as "Compassionate") and the undersigned client (referred to as "Client"). By signing this agreement, the Client acknowledges and agrees to the terms outlined below:

Accuracy of Information
The Client affirms that all information provided during the intake process is accurate and complete to the best of their knowledge. The Client agrees to promptly notify Compassionate of any changes to the information provided.

Use of Information
Compassionate will use the information provided solely for the purpose of assessing the Client’s needs and determining the availability of suitable services.

Confidentiality
Compassionate is committed to maintaining the confidentiality of the Client’s information. The information collected during the intake process will not be shared with any third parties without the Client’s explicit written consent unless required by law.

Acknowledgment
By signing below, the Client confirms their understanding and acceptance of the terms outlined in this agreement.

I confirm that the information provided is accurate to the best of my knowledge and agree to the terms stated above.

Print Name*

Signature*

Date

Form Filled by: FOR OFFICE STAFF ONLY

Nurse Supervisor

Employee Name: (PRINT NAME)

Time of call

Appointment Day

Time

Intake Application For New Clients

CONTACT INFORMATION

Client Information

Insurance Information

Service

AGREEMENT