Clone of Full Client Intake Form

Full Client Intake Form

Please fill out the sections with your information to help us understand your needs and preferences.
Client Demographics
Legal Name

First NameLast Name
Preferred Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender

Other
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
County
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Living Arrangement
Primary Language
Emergency Contact Name

First NameLast Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Relationship
Responsible Party / Payer
Responsible Party Name

First NameLast Name
Relationship to Client
Responsible Party Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Responsible Party Phone
Please enter a valid phone number.Format: (000) 000-0000.
Responsible Party Email
example@example.com
Billing Contact (if different)
Who Signs Documents?
Referral Information
Referral Source
Referral Type
Referral Phone/Email
Date of Referral

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Referral Code
Services Requested
Which services are requested?

Other
Schedule Needs
Days Needed
Preferred Shift Times
Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Urgency
Minimum Hours Requested
Weekend Care Needed?
Overnight Care Needed?
Live-in Care Requested?
Payment Source
Payment Source

Other
If insurance/waiver is selected, please provide the following:
Plan Name
Member ID
Case Manager
Authorization Number (if applicable)
Clinical/Safety Snapshot
Diagnoses/Conditions
Mobility Status
Fall Risk?
Transfer Assistance Needed?
Dementia/Confusion?
Oxygen?
Incontinence?
Skin Issues?
Allergies?
Behaviors/Safety Concerns?
Pets in Home?
Smoking in Home?
Weapons in Home?
Infection Precautions?
Consent and Acknowledgement
Consent to be contacted
Consent to collect information
HIPAA/Privacy Acknowledgement
Electronic Signature
Should be Empty:

Full Client Intake Form

Client Demographics

Responsible Party / Payer

Referral Information

Services Requested

Schedule Needs

Payment Source

If insurance/waiver is selected, please provide the following:

Clinical/Safety Snapshot

Consent and Acknowledgement