New Client Intake & Medical History Form

SAFE HOME ASSESSMENT PROGRAM™

Client Profile & Needs Assessment Form
Client Full Name

First NameMiddle NameLast NameSuffix
Client Preferred Name
Client Birth Date

MonthDayYear
Marital Status
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Mobile Phone Number

Area CodePhone Number
E-mail
Please indicate which is your preferred method of contact (email, text, phone call, etc.)
How were you referred to Safe-Step 123?

Client Additional Information

We’d love to know a bit more. Most importantly, who should we contact if we have an urgent need to communicate with you, but you’re not reachable?
Your Occupation:
What Industry do/have you worked in?
Emergency Contact

First NameLast Name
Phone Number

Area CodePhone Number
Relationship

Spouse/Partner Information

If you do not have a significant you’d like listed, please select “Not Applicable” below. Otherwise, please share a bit about your partner below.
I do NOT have a Spouse/Partner.
Partner's Full Name

First NameMiddle NameLast NameSuffix
Address (if different than client)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Partner's Phone Number

Area CodePhone Number
E-mail
example@example.com
Occupation
Industry

Caregiver Input (Optional)

If applicable, please request your that your caregiver fill out the below, therefore allowing us their concern and perspective.
Name

First NameLast Name
Relationship:
Primary Concerns
Additional Comments:

Investment Comfort Range

We ask the following solely to allow us perspective as to how we can most assist with assuring you’re circumstance is understood.
If improvements are recommended, what budget range would you be comfortable exploring?

Client Acknowledgement
I understand that the Safe Home Assessment Program™ is designed to identify potential safety risks, accessibility concerns, and aging-in-place opportunities within my home. The assessment is intended to provide recommendations and does not constitute medical, engineering, or legal advice.
Client Signature:
Date

MonthDayYear
Date
Should be Empty:

SAFE HOME ASSESSMENT PROGRAM™