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
Date
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.
E-mailHome PhoneCell Phone
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.
EmailHome PhoneCell Phone
YesNo
Relationship to Client
YesNo
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.
EmailHome PhoneCell Phone
YesNo
Relationship to Client
YesNo
Living Environment
HomeApartmentAssisted LivingOther
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:
IndependentCane assistedWalker assistedWheelchair assistedOther assistance needed
Vision or hearing impairments:
Communication preferences:
Services Requested
Regular visits and companionshipRegular phone call check-insAccompaniment on walks or outdoor timeMedication remindersLight housekeeping and choresLaundry assistanceMeal preparation and kitchen tidyingGrocery shoppingErrand assistanceTransportation to appointments or activitiesNote-taking at medical appointmentsLight yard workOn-call supportTechnology assistanceSnow shoveling and saltingOther
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.
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:
Assistance needed (meal prep, reminders to eat, grocery support, etc.):
Light Housekeeping & Home Support
Areas needing routine attention:
Laundry preferences / instructions:
Cleaning products to use or to avoid:
Transportation & Errands
YesNo
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
YesNo
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
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
*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