Intake Form
A Program of the Clinch-Powell Resource Conservation & Development Council, Inc.
Appalachia CARES Living in Place Program
GAP Services for Seniors and Individuals with Disabilities
Purpose of this form:
This intake form gathers information to help Appalachia CARES staff and AmeriCorps members understand the client's needs, preferences, and home environment. The program does not provide prescription, medical, mental health, or emergency services.
Section 1: Client Information
Client Name:
*
Preferred Name (if different):
Date of Birth:
*
-
Month
-
Day
Year
Date
Age:
Sex:
Male
Female
Prefer not to say
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number:
*
Alternate Phone Number:
Email Address (if applicable):
example@example.com
Best Way to Contact You:
*
Phone
Text
Email
Section 2: Household & Living Situation
Do you live:
Alone
With Spouse/Partner
With Family
Other
Type of Residence:
House
Apartment
Mobile Home
Other
Do you rent or own your home?
Own
Rent
Other
Primary Source(s) of Income:
Employment
Social Security
Retirement
Disability
Other
Are you able to financially contribute to home modification if applicable?
Yes
No
Maybe
Are there pets in the home?
Yes
No
If yes, please describe (type/number):
Section 3: Daily Living & Support Needs (Non-Prescription, Medical, Health or Emergency Related)
(Please check any areas where you would like assistance.)
Meal planning or grocery list support (does not include meal prep or grocery shopping)
Light organization or household tasks
Minor home safety or accessibility support
Lawn care or basic outdoor maintenance
Social activities (games, reading, conversation)
Other
Additional Notes:
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Intake Form
A Program of the Clinch-Powell Resource Conservation & Development Council, Inc.
Section 4: Mobility & Allergy Information
Mobility Status:
Independent
Uses Cane or Walker
Wheelchair
Allergies (including food allergies):
Section 5: Communication & Preferences
Primary Language Spoken:
Do you require assistance with communication (hearing, vision, reading)?
Yes
No
If yes, please describe:
Are there days/times that work best for visits?
Is there anything staff or AmeriCorps members should know to make visits more comfortable for you?
Section 6: Safety & Home Visit Information
Are there any safety concerns staff or AmeriCorps members should be aware of before visiting your home?
Yes
No
If yes, please describe (e.g., pets, walkways, parking instructions, primary entrance):
Emergency Contact Name:
Relationship:
Phone Number:
Section 7: Consent to Participate
I understand that the Appalachia CARES Living in Place Program does not provide prescription,
medical, mental health, or emergency services. Services may be provided by staff or AmeriCorps
members and may include social support, assistance with daily living activities, minor home safety
support, and other non-prescription, non-medical, non-mental health, and non-emergency assistance.
Voluntary Participation:
I understand that my participation in the Appalachia CARES Living in Place Program is voluntary, and I
may withdraw consent for services at any time.
Section 8: Liability Release
The Appalachia CARES Living in Place Program provides assistance aimed at promoting safety,
independence, and well-being for older adults. While all reasonable precautions are taken to ensure client
safety, participation in home-based services is voluntary and involves the following acknowledgements.
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Intake Form
A Program of the Clinch-Powell Resource Conservation & Development Council, Inc.
Nature of Services:
I acknowledge that Appalachia CARES Living in Place Program staff and AmeriCorps members may enter my home to conduct services and support. These services are non-prescription, non-medical, non-mental health, and non-emergency in nature. The services are not to replace prescription, medical, mental health, or emergency care.
Assumption of Risk:
I understand and voluntarily assume any and all risks associated with participation in these services, including but not limited to accidents, falls, or property damage that may occur during or after a visit.
Release of Liability:
I understand that while reasonable care is taken, participation in program services may involve certain risks associated with in-home activities. To the fullest extent permitted by law, I agree to release and hold harmless Appalachia CARES Living in Place Program, the Clinch-Powell Resource Conservation & Development Council, Inc., its staff, AmeriCorps members, partners, and affiliates from any liability, claims, or damages arising from participation in the non-prescription, non-medical, non-mental health, and non-emergency services, except in cases of gross negligence or willful misconduct.
Emergency Protocol:
I understand that the Appalachia CARES Living in Place Program staff and AmeriCorps members are not medical personnel or emergency responders. In the event of a medical emergency, the program will contact 911 or emergency services as appropriate.
Consent for Communication and to Enter Home:
I authorize the Appalachia CARES Living in Place Program staff, AmeriCorps members, and designated representatives to enter my home for the purpose of providing services as outlined in my gap services assistance plan. I give permission for program staff or AmeriCorps members to contact me by phone, text, email, or mail. I understand that I may withdraw this consent at any time by notifying the program.
Confidentiality:
All personal information shared with the Appalachia CARES Living in Place Program will be maintained in confidence in accordance with applicable privacy laws and program policies.
Acknowledgment and Signature:
By signing below, I acknowledge that I have read, understood, and voluntarily agree to the terms of the Consent to Participate, Liability Release, and Acknowledgment in sections seven (7) and eight (8) of this form.
Client Name:
Client Signature:
Date:
-
Month
-
Day
Year
Date
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