Gateway Holistic
9218 Ellerslie RD SW, Ste 195,
Edmonton, AB, T6X0K6
info@gateway-holistic.com
www.gateway-holistic.com
(780) 239 6674
New Client Intake Form
Client Details:
Full Name
*
First Name
Last Name
Gender:
*
Male
Female
Other
Date of birth:
*
-
Month
-
Day
Year
Please select your birthday
Current Age:
Height:
Weight:
Can you provide your Healthcare Card number?
*
Yes
No
Please provide the number on your Healthcare Card:
*
What is the expiration date on your Healthcare Card?
*
-
Month
-
Day
Year
If a specific date is not provided - please select the first day of your expiration month.
What Province/Territory was your Healthcare Card issued by?
*
e.g. Alberta
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Email
*
example@example.com
Parent/Guardian Name
*
First Name
Last Name
Are you the legal guardian of the child?
*
Yes
No
Please Provide the Name of the Legal Guardian of the Child
*
First Name
Last Name
Do you have sole custody or shared custody?
*
Yes - Sole Custody
Yes - Shared Custody
Neither
Do you have a court order in place?
*
Yes
No
Do you understand that Gateway Holistic Care Group is not able to facilitate or arrange parental visits between your child and the parent listed in the court order, and that it is the responsibility of the legal guardian to arrange and manage these visits? Gateway Holistic Care Group cannot assume this responsibility.
*
Yes - I understand.
No - I do not understand.
Primary language spoken at home:
*
Please let us know what program(s) you are interested in at Gateway Holistic. Select all that apply.
Supported Living
Respite
Child & Youth
When are you looking for services to start?
*
-
Month
-
Day
Year
Please select a date
Would you like to sign up for Respite services on Holidays and/or PD Days?
*
Yes
No
Please select your ideal shift dates:
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
What times do you need care on Monday's?
*
e.g. 9am-5pm
What times do you need care on Tuesday's?
*
e.g. 9am-5pm
What times do you need care on Wednesday's?
*
e.g. 9am-5pm
What times do you need care on Thursday's?
*
e.g. 9am-5pm
What times do you need care on Friday's?
*
e.g. 9am-5pm
What times do you need care on Saturday's?
*
e.g. 9am-5pm
What times do you need care on Sunday's?
*
e.g. 9am-5pm
What type(s) of care are you looking for? Please check all that apply.
*
In-home Respite
Out-of-home Respite
Personal Care
Community Access
Holiday/Vacation Care
Hospital to Home Care
Live-In Care
Supported Living
Dementia Care
Where would you like the services to mainly take place?
*
What is the client's clinical diagnosis?
*
What level of care does the client require?
*
Level I
Level II
Level III
Preference in the gender of the caregiver?
*
Male caregiver
Female caregiver
No preference
Does the client have any food allergies?
*
Beans
Citrus
Dairy
Eggs
Mushrooms
Nuts/Peanuts
Shellfish/Seafood
Strawberries
Tomatoes
None
Other
Does the client have any dietary restrictions?
*
Celiac
Diabetic
G-Tube Fed
High Protein
Lactose Intolerant
No Meat
No Pork
Soft Foods Only
Vegetarian
Vegan
None
Other
Does the client have any environmental allergies?
*
What level of assistance does the client require for Personal Care?
*
Maximum Assistance
Pivot Transfers
Stand by Assist
Other
Does your family have any animals at home? Please tell us about any pets that live with the client.
*
Any recent history of falls?
*
Does the client smoke?
*
Does the client use any substances (drugs, alcohol, etc)?
*
Risk Factors - Please select all that apply:
*
Combative
Abusive (mentally and/or physically)
Disruptive
Repetitive
Withdrawn
Self-harm Tendencies
Dementia/Alzheimer's
Elopement
Wanderer
None of the above
What is the clients impairment level:
*
Alert
Alert (occasional confusion)
Mild Impairment (some confusion)
Moderate Impairment (confused, trouble with memory)
Severe Impairment (affects all aspects of life)
Other
How does the client sleep?
*
Awake through the night
Sleep soundly through the night
Intermittent sleep through the night
Other
What is the clients general mood like?
*
Pleasant
Anxious
Agitated
Other
Please describe any cultural, communication, or language barriers we should know about:
*
Please indicate whether the client uses any of the following communication helpers:
*
Communication Board
Picture Book
Computer/Tablet
Sign Language
None
Other
Please describe any specific triggers and/or calming strategies used with the client:
*
Please describe the client's current living arrangements:
*
Please tell us about the clients main support system:
*
Are you covered under any private insurance? If yes, please tell us who your plan is with.
*
Does the client enjoy interacting with others?
*
Please tell us 3-5 of the clients favorite activities to help us get to know them better!
*
Does the client take medications?
Yes
No
Please tell us: (name, type, instructions, dose/frequency, start from, duration, quantity)
*
Complete one box per medication
Please tell us: (name, type, instructions, dose/frequency, start from, duration, quantity)
Complete one box per medication
Please tell us: (name, type, instructions, dose/frequency, start from, duration, quantity)
Complete one box per medication
Family Physician
Doctor's Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Name of Clinic:
*
Family Pharmacist
Name of Pharmacy:
*
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
FSCD/PDD
Is the client an FSCD or PDD Client?
Yes
No
FSCD/PDD Case Worker's Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Please upload the clients FSCD/PDD Agreement here for our team to review:
*
Browse Files
Drag and drop files here
Choose a file
**Please Note: If you do not have your FSCD Agreement on hand/do not have an updated agreement yet, please upload a blank document (or show us a photo of your kiddo!) - you will be able to email us the Agreement in the next phase of the Intake Process.
Cancel
of
How many hours per month does the clients FSCD/PDD contract allow for Respite and Overnight care?
*
How many hours per month does the clients FSCD contract allow for Out of School care?
CSS/CFS
Is the client in the care of CSS or CFS?
*
Yes
No
CFS/CSS Caseworkers Name
*
First Name
Last Name
Caseworkers Email
*
example@example.com
Emergency Contact Information:
Full Name
*
First Name
Last Name
Phone Number
*
Email
*
example@example.com
Relationship to Client:
Are you currently working with another agency?
*
Yes
No
Will you be working with Gateway Holistic and the other agency?
*
Yes
No
Why are you exploring switching to another agency?
*
How did you learn about us?
*
Please Select
FSCD guided us to you.
I was Referred to you.
I found you on Social Media.
Word-of-mouth.
Other
Please Specify
Please provide the name of the person or organization that referred you to us.
*
Submit
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