Client Intake Form

Client Intake Form- Webb's Health and Home Care LLC

Phone: 863-698-7696 Email:info@webbshhc.com Address: 5304 S Florida Ave STE 400-G Lakeland FL 33813
Full Name
Date of Birth

MonthDayYear
Date
Age
Gender

MaleFemaleOtherPrefer not to say
Social Security Number last 4 digits
Medicaid ID
APD ID if applicable
Address
City
State
ZIP
Phone Number
Email Address if available
example@example.com
Name
Relationship to Client
Phone Number
Alternate Number
SECTION 3: Authorized Representative / Guardian (if applicable)
Full Name
Relationship to Client
Phone Number
Email Address
example@example.com
Legal Authority

GuardianPOAParentOther
SECTION 4: Medical Information
Primary Diagnosis Disability
Secondary Diagnoses if any
Allergies

NoYes
Please list
Primary Physician
Phone
Medications (list or attach)
Mobility Needs

IndependentCaneWalkerWheelchair
Does client use oxygen

YesNo
Special Equipment Needed
Requested Services

Personal Care AssitanceLife Skills DevelopmentAPD IBudget Waiver ServicesOther
SECTION 6: Availability for Services
Preferred Days

MondayTuesdayWednesdayThursdayFridaySatSun
Preferred Time

MorningAfternoonEveningOvernight
Hours per week requested
Referral Source

SelfFamily MemberAPD Support CoordinatorHospitalCase ManagerOther
SECTION 8: Consent & Signature

By signing below, I confirm that the information provided is accurate to the best of my knowledge and that I am requesting home and/or personal care services from Webb's Health and Home Care LLC.

Client or Guardian Signature: Staff Receiving Intake:
Client or Guardian Signature

Clear
Date

MonthDayYear
Date
Staff Receiving Intake
Date

MonthDayYear
Date
Should be Empty: