Client Intake Form

Client Intake Form
Client Name

First NameLast Name
Client Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Marital Status
Email
example@example.com
Primary Care Provider
Referral Name

First NameLast Name
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Preferred Method of Contact
Emergency Contact Information
Name

First NameLast Name
Email
example@example.com
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Prefered Method of Contact
Do you authorize Joan's Care to text the cell phone number listed above?
Relationship to Client
Does the Client authorize Joan’s Care to share relevant care updates and safety information with the Emergency Contact listed above if necessary?
Primary Contact Information

(If different than Emergency Contact Information)
Name

First NameLast Name
Email
example@example.com
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Prefered Method of Contact
Do you authorize Joan's Care to text the cell phone number listed above?
Relationship to Client
Do you authorize Joan’s Care to share relevant care updates and safety information with the Emergency Contact listed above if necessary?
Living Environment
Type of Residence

Other
Does the Client live alone? If no, please describe:
Are there pets in the home? If yes, please describe:
Are there any safety considerations we should know about?
Parking instructions (if applicable):
Daily Routine & Preferences
Typical wake-up and bedtime:
Preferred daily routine:
Favorite activities or hobbies:
Mobility level
Vision or hearing impairments:
Communication preferences:
Services Requested
Please check all services you are interested in:

Other
Companion Care & Social Engagement
Topics the Client enjoys discussing:
Faith or spiritual preferences (if applicable):
Any activities that bring the Client comfort or joy:
Medical Information

Note: Joan’s Care provides medication reminders and checks only. We do not administer medications.
Does the Client have a signed CPR Directive (a.k.a. Do Not Resuscitate Order)?**Note: If “Yes,” Joan’s Care must be provided a copy of the signed order, or we will not be held liable for providing Basic Life Support or CPR in the event of an emergency.
If "Yes", please submit a copy of the Signed CPR Directive here.

Cancelof
Medication name(s), dosage(s), purpose(s), and schedule(s).
Are there any medications requiring reminders?
Allergies to medications:
Pharmacy name, address and phone number:
Meal & Nutrition Support
Dietary restrictions or allergies:
Preferred foods and favorite meals:
Foods to avoid:
Light Housekeeping & Home Support
Areas needing routine attention:
Laundry preferences / instructions:
Cleaning products to use or to avoid:
Transportation & Errands
Do you require transportation?
Typical destinations (appointments, church, grocery store, etc.):
Mobility assistance needed when entering/exiting vehicle:
Preferred temperature in vehicle:
What music or radio stations do you enjoy during rides?
Outdoor & Activity Support
Interest in / preferences for walks or outdoor activities:
Desire for and comfort level with pool or recreation center visits:
Physical limitations or safety concerns:
Comfort & Personal Preferences
Our care providers tend to dress casually (e.g., sweatshirts, t‑shirts, jeans, shorts, tennis shoes, sandals) to create a relaxed and approachable environment. Would this style of dress make you or anyone in the home uncomfortable?
If yes, please explain preferences:
Preferred name for caregiver to use:
Any culture or personal preferences we should be aware of and respect:
Anything that may cause anxiety or discomfort:
Safety & Health Considerations
Fall risk concerns:
If possible, emergency procedures we should follow (Joan's Care will call 9-1-1 in the event of an emergency).
Physician(s) name, practice and phone number:
Hospital preference:
Scheduling Preferences:
Desired start date:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Preferred days, times and durations:
Frequency of visits:
Additional Notes
Please share anything else that would help us provide exceptional care and companionship:
Privacy & Security Information
Joan’s Care is committed to protecting the privacy and confidentiality of all client information. Any personal, medical, household, or contact information collected is used solely for the purpose of providing safe, personalized care and coordinating services.

Client information will never be sold or shared for marketing purposes.

Information will only be shared with care providers assigned to your services and, when necessary, with emergency personnel or authorized family contacts.

Written and digital records are stored securely and accessed only as needed to deliver care.

You may request to review, update, or correct your information at any time.

By signing below, you acknowledge that you have read and understand how Joan’s Care collects, uses, and protects your information.
Form Submission Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
*Your signature below indicates that the information you have provided above is truthful, and you agree to the services provided by Joan's Care.
Client Signature
Primary Contact Signature
Should be Empty:

Client Intake Form

Emergency Contact Information

Primary Contact Information

Living Environment

Daily Routine & Preferences

Services Requested

Companion Care & Social Engagement

Medical Information

Meal & Nutrition Support

Light Housekeeping & Home Support

Transportation & Errands

Outdoor & Activity Support

Comfort & Personal Preferences

Safety & Health Considerations

Scheduling Preferences:

Additional Notes

Privacy & Security Information