Consumer Intake Form — Benevolent Hearts Home Care LLC

Consumer Intake Form — Benevolent Hearts Home Care LLC

Provide accurate personal, emergency, health, and care needs details to create your care profile.
Consumer / Client Information
Full Name

First NameLast Name
Date of Birth (MM-DD-YYYY)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Social Security Number
Medicaid Number
Medicare Number
Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Alternate 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
Primary Language Spoken
Are there any communication barriers?
If yes, please describe the communication barriers.
Emergency Contact & Responsible Party
Emergency Contact Name

First NameLast Name
Relationship to Consumer
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Responsible Party / Legal Guardian Name (if different)

First NameLast Name
Relationship
Responsible Party Phone
Please enter a valid phone number.Format: (000) 000-0000.
Is there a Power of Attorney?
Power of Attorney Name
Power of Attorney Phone
Please enter a valid phone number.Format: (000) 000-0000.
Is there a DNR (Do Not Resuscitate) order on file?
Is there an Advance Directive on file?
Medical Background & Health Information
Primary Physician / Doctor Name
Physician Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Physician Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Primary Diagnosis
Secondary Diagnosis
Current Medications (list all medications and dosages)
Known Allergies
Medical Equipment in Use

Other
Mobility Status
Is there a fall risk?
Have there been hospitalizations in the last 12 months?
If yes, please provide details of recent hospitalizations.
Care Needs & Service Authorization
Types of Care Needed

Other
Preferred Schedule
Hours of Care Needed per Week
Special Instructions or Notes for Caregiver
Does the consumer have pets?
Is there smoking in the home?
Are there any safety hazards in the home?
If yes, please describe the safety hazards.
I hereby authorize Benevolent Hearts Home Care LLC to provide home care services as discussed and outlined in my care plan. I understand that services may be modified based on my needs. I certify that the information provided above is accurate and complete.
Consumer / Legal Guardian Signature
Date (MM-DD-YYYY)

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

Consumer Intake Form — Benevolent Hearts Home Care LLC

Consumer / Client Information

Emergency Contact & Responsible Party

Medical Background & Health Information

Care Needs & Service Authorization