Client Intake Form
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Email
example@example.com
Relationship to Client
Care Needs Overview
Primary Reason for Requesting Care:
Senior care
Disability support
Post-surgery recovery
Daily living assistance
Medicaid caregiver enrollment
Home accessibility assistance
Brief Description of Care Needs:
Daily Hours of Care Needed:
Morning
Afternoon
Evening
Overnight
Full-day support
Medical & Safety Information
Primary Diagnosis (if applicable):
Secondary Conditions:
Mobility Level:
Independent
Needs assistance
Wheelchair
Bedbound
Any Behaviors or Safety Concerns?
Current Medications:
Allergies:
Living Situation
Who Lives in the Home?
Is the Home Safe and Accessible?
Yes
Needs modifications
Not sure
Pets in the Home?
Yes
No
Insurance & Coverage
Medicaid Status:
Active Medicaid
Needs help applying
Private pay
Other
Medicaid Waiver (if known):
A&D
TBI
CIH
Not sure
Member ID Number (if available):
Family Caregiver Option
Do you have a family member who wants to be your caregiver?
Yes
No
Other
Caregiver’s Name:
First Name
Last Name
Caregiver’s Relationship to Client:
Caregiver Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Home Accessibility Assistance (Optional)
Are you requesting Medicaid-funded home modifications?
Yes
No
Modifications Needed:
Wheelchair ramp
Grab bars
Accessible bathroom
Stair lift
Other
If Other please describe:
Preferred Start Date
-
Month
-
Day
Year
Date
Additional Notes
Client or Representative Name:
First Name
Last Name
Signature
Date
-
Month
-
Day
Year
Date
Continue
Continue
Should be Empty: