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
Height:
Weight:
Can you provide a form of Government issued ID?
*
Alberta Healthcare Card
Passport
Drivers License
Other
Please provide the number on your ID:
*
Healthcare number, Drivers License number, Passport number, etc.
What is the expiration date on your ID?
*
-
Month
-
Day
Year
If a specific date is not provided - please select the first day of your expiration month.
What Province/Territory was your ID 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
Primary language spoken at home:
*
Is there a DNR (Do Not Resuscitate) in place?
*
No
Yes
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 your clinical diagnosis?
*
What level of care do you require?
*
Level I
Level II
Level III
Preference in the gender of the caregiver?
*
Male caregiver
Female caregiver
No preference
Do you have any food allergies?
*
Beans
Citrus
Dairy
Eggs
Mushrooms
Nuts/Peanuts
Shellfish/Seafood
Strawberries
Tomatoes
None
Other
Do you have any dietary restrictions?
*
Celiac
Diabetic
G-Tube Fed
High Protein
Lactose Intolerant
No Meat
No Pork
Soft Foods Only
Vegetarian
Vegan
None
Other
Do you have any environmental allergies?
*
What level of assistance do you require for Personal Care?
*
Maximum Assistance
Pivot Transfers
Stand by Assist
Other
Do you have any animals at home? Please tell us about any pets that live with you.
*
Any recent history of falls?
*
Do you smoke?
*
Do you 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 your 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 do you sleep?
*
Awake through the night
Sleep soundly through the night
Intermittent sleep through the night
Other
What is your general mood like?
*
Pleasant
Anxious
Agitated
Other
Please describe any cultural, communication, or language barriers we should know about:
*
Please indicate whether you use 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:
*
Please describe your current living arrangements:
*
Please tell us about your main support system:
*
Are you covered under any private insurance? If yes, please tell us who your plan is with.
*
Do you enjoy interacting with others?
*
Please tell us 3-5 of your favorite activities to help us get to know you better!
*
Do you 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
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
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
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
Are you 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 your 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 your FSCD/PDD contract allow for Respite care?
*
How many hours per month does your FSCD contract allow for Out of School care?
How many hours per month does your FSCD/PDD contract allow for Overnight care?
*
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 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
Submit
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