ASCL Home Care Intake Form

ASCL Home Care Intake Form

Please complete this mobile-friendly intake form using the section order and labeling from the attached PDF reference.
Client Information
Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Gender
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Social Security Last 4
Marital Status
Address & Living Situation
Street Address
City
State
ZIP Code
Type of Residence
Living Arrangement
Entry Access Notes
Emergency Contacts
Primary Contact Name
Primary Contact Relationship
Primary Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Contact Name
Secondary Contact Relationship
Secondary Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Insurance/Payment Information
Payment Type
Insurance Provider
Policy / ID Number
Group Number
Case Manager Name
Case Manager Agency
Case Manager Phone
Please enter a valid phone number.Format: (000) 000-0000.
Medical Providers
Primary Care Physician
Physician Phone
Please enter a valid phone number.Format: (000) 000-0000.
Specialist(s)
Preferred Pharmacy
Pharmacy Phone
Please enter a valid phone number.Format: (000) 000-0000.
Medical History
Primary Diagnosis
Other Medical Conditions
Mental Health Diagnoses
Allergies (food, medication, environmental)
Current Medications (Name / Dosage / Frequency)
Functional Assessment (ADLs)
ADLs - Bathing
ADLs - Dressing
ADLs - Toileting
ADLs - Transferring
ADLs - Mobility
ADLs - Eating
Instrumental Activities (IADLs)
Meal Preparation
Housekeeping
Laundry
Transportation
Medication Management
Shopping
Mobility & Equipment
Mobility Status
Uses Assistive Devices
Assistive Devices Used
Safety & Risk Assessment
Fall Risk
Falls in Last 6 Months
Wandering Risk
Cognitive Impairment
Substance Use Concerns
Home Safety Concerns
Service Preferences
Personal Care Needs

Other
Homemaker / Support Services

Other
Preferred Days
Preferred Times
Hours per Week
Start Date Requested

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Additional Notes / Special Requests
Authorization
Client / Guardian Name

First NameMiddle NameLast Name
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

ASCL Home Care Intake Form

Client Information

Address & Living Situation

Emergency Contacts

Insurance/Payment Information

Medical Providers

Medical History

Functional Assessment (ADLs)

Instrumental Activities (IADLs)

Mobility & Equipment

Safety & Risk Assessment

Service Preferences

Authorization