Client Intake Form

Client Intake Form

Please complete this form to help us understand your care needs and set up services with Glorious Emerald Care Group LLC.
Client Information
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Who is the responsible party for care decisions?
Responsible Party Details
Responsible Party Full Name

First NameLast Name
Relationship to Client
Responsible Party Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Responsible Party Email
example@example.com
Emergency Contact
Emergency Contact Name

First NameLast Name
Relationship to Client
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Care Needs and Daily Living Support
Which activities does the client need help with?

Other
Medical and Safety Information
Primary Medical Conditions
Allergies
Does the client take medications?
List current medications
Does the client use any mobility aids?

Other
Does the client have any safety concerns (e.g., fall risk, wandering)?
Upload relevant medical documents (optional)

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Home and Environment Details
Type of residence
Are there pets in the home?
If yes, please specify type and number of pets
Are there any home safety hazards we should be aware of?
Schedule and Service Setup
Preferred days for service
Preferred time of day
Preferred start date for services

MonthDayYear
Date
Care Preferences
Preferred caregiver gender
Preferred language for communication
Other care preferences or special instructions
Payment and Billing Information
Who will be responsible for payment?

Other
Type of payment method

Other
Upload insurance or payment documents (optional)

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Consent and Signature
Signature
Should be Empty:

Client Intake Form

Client Information

Responsible Party Details

Emergency Contact

Care Needs and Daily Living Support

Medical and Safety Information

Home and Environment Details

Schedule and Service Setup

Care Preferences

Payment and Billing Information

Consent and Signature