🌟 Golden Glow Visits – Client Intake Form
Welcome to Golden Glow Visits! We’re honored that you’re considering us to support you or your loved one. This intake form helps us learn more about the client’s needs, preferences, and daily routines so we can provide the most personalized and compassionate care possible. All information is kept private and secure, and nothing will ever be shared without permission. Completing this form only takes a few minutes, and it helps us match you with the right visit type and companion services. After submission, we’ll reach out within 24 hours to confirm details and schedule your first Golden Glow Visit.
Client Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
*
Male
Female
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Preferred Contact Method
*
Please Select
Phone
Email
Text
Emergency Contact Name
*
First Name
Last Name
Relationship
*
Phone Number
*
Please enter a valid phone number.
Secondary Contact (optional)
Please enter a valid phone number.
Primary Physician
First Name
Last Name
Known Medical Conditions
Allergies
*
Current Medications
Hearing/Vision Concerns?
Communication Needs (slow speech, memory support, hearing device, etc.)
Mobility Needs
*
Please Select
Independent
Walker
Wheelchair
Needs Assistance
Type of Visit Interested In
Quick Check-In (30 min)
Golden Hour (1 hr)
Radiance Visit (2+ hrs)
Sunshine Stroll
Glow & Go (transportation)
Mini Errand Run
Pet Pals Add-On
Preferred Days/Times
Additional Notes or Requests
Consent & Agreement
*
“I acknowledge that Golden Glow Visits is a companionship service and does not provide medical or nursing care.”
“I agree to the privacy and cancellation policies.”
Signature
*
Today's Date
*
-
Month
-
Day
Year
Date
Submit
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