Alpha Care Family Services Intake Form

Alpha Care Family Services

Intake Form
Date:

MonthDayYear
Date
PCA Service:
Case Manager:
Client Name:

First NameLast Name
Date of Birth:

MonthDayYear
Date
Age:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email Address:
example@example.com
Diagnosis:
Payer Source:
MA ID#:
When was the PHN Assessment completed?
PCA Hours Authorized:
Do you have a copy of your PHN Assessment or Service Agreement?
If "yes", would you like to request a copy?
Responsible/Legal Representative Name:

First NameLast Name
Relationship:
Home Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email Address:
example@example.com
Note: Traditional clients needs - RP must have 15 hour minimum.
Male or Female preferred?
How did you hear about Alpha Care Family Services?
Referral Name:
Home Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Are you transferring from another company?
If "yes", please provide more information below. Please allow up to 3 weeks for the change to go into affect.
Company Name:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number:
Please enter a valid phone number.Format: (000) 000-0000.
PCA Intake Request Lines

Hennepin County: (612) 348-4500, (612) 348-4111
Ramsey County: (651) 266-2400, (651) 266-4444
Anoka County: (763) 324-1450
Dakota County: (952) 891-7500, (651) 554-6115
Washington County: (651) 430-6484
Chisago County: (651) 213-5600
Isanti County: (763) 689-4071

For other counties, please call the County PHN or Social Worker.
Should be Empty: