Like Family We Care: Client Intake Form
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Ethnicity
Black or African American
Hispanic or Latino
White or Caucasian
American Indian or Alaska Native
Asian or Pacific Islander
Service Coordinator Name
First Name
Last Name
Service Coordinator Number
Please enter a valid phone number.
Select what LFWC services you need (select all that apply)
Personal Care
Companionship
Medication Assistance
Light House Keeping
Meal Prep
Laundry Services
Errands & Shopping
Other
Briefly describe what needs you need help with on a daily basis and why
What duration do you expect to need health care services
Who is your health insurance provider?
UPMC Life Changing Medicine
Keystone First: Community Health Choices
PA Health & Wellness
Other
If "OTHER", please list
List of medication along w/ dosage and frequency
Do you have pets in the home?
Yes
No
Do you have children in the home?
Yes
No
If YES to children, how many?
Do you own a vehicle?
Yes
No
How would you rate your health in general?
Good
Mild
Bad
Terrible
Have you fallen 2 or more times in the past year?
Yes
No
Acknowledge that your caregiver is
Representative Payee
Spouse
POA (Power of Attorney)
Parent/ Legal Guardian
None of the above
During the past 4 weeks:
Have you been bothered by emotional problems such as anxiety, depression, irritation, or sadness?
Has your physical and emotional health limited social activities?
None of the above
Emergency Contact Name
First Name
Last Name
Emergency Contact Number
Please enter a valid phone number.
Emergency Contact Email
example@example.com
Please verify that you are human
*
Submit
Should be Empty: