Client Intake Form
Phone: (336) 291-8401 Email: goodtimeshomehealth@gmail.com
Are you receiving support in completing this form?
Yes
No
If yes, what is the name, contact number, and relationship of the person assisting you?
Client Full Name
First Name
Last Name
Age
Date of Birth
Race/Ethnicity
Please Select
White
Black/African American
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Hispanic/Latino
Marital Status
Please Select
Single
Married
Divorced
Widow
Separated
What is your gender?
Contact Number
Format: (000) 000-0000.
Email Address
example@example.com
Zip Code
Address
City and State
Living Arrangement
Alone
With Someone
If living with someone who are they in relation to you?
Last Doctor's Visit
-
Month
-
Day
Year
Date
Daily Tasks Needed
Eating
Dressing
Bathing
Toileting
Mobility
Services Requested
Medicaid
Personal Care Services
Private Pay
Transportation
Other
Emergency Contact
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship
How did you hear about us?
Please Select
Social Media
Family/Friend
Doctor Office
Signage Display
Other
Schedule Follow Up Appointment
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Should be Empty: