Client Intake & Care Preferences
The Social Age | Care for the life you're living.
Welcome to The Social Age.
We believe good support starts with knowing the person, not just what they need help with. This form gives us the information needed to plan safe, personalized, non-medical services.
Client Information
Name
*
First Name
Last Name
Preferred name:
Date of birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address where services will be provided:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Pronouns
Primary Contact
Name
First Name
Last Name
Relationship to client
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Does client make their own decisions regarding services?
Please Select
Yes
Yes, with assistance
No - an authorized representative makes decisions
Emergency Information
Emergency Contacts - Names, Relationships, Phone numbers
Preferred hospital, if known
Primary care provider
Health & Safety Information
Please provide information relevant to safely providing non-medical services. The Social Age does not diagnose or provide medical treatment.
Known allergies
Relevant health conditions or diagnoses we should know about:
Mobility:
Independent
Cane
Walker
Wheelchair
Requires assistance
Other
Fall history or current fall concerns:
Hearing needs:
Memory/cognitive concerns:
None known
Mild memory changes
Dementia diagnosis
Alzheimer's disease
Other cognitive impairment
Prefer to discuss privately
Does the client have a history of wandering/elopement?
No
Yes
Unsure
Any behaviors, triggers, fears, or situations we should be aware of?
Dietary restrictions, allergies, texture requirements, or preferences:
Does the client use oxygen or other medical equipment?
No
Yes
Are there pets in the home?
No
Yes
If yes, please describe pets and anything we should know:
Are there firearms or other potential safety hazards in the home?
No
Yes
Prefer to discuss directly
If applicable, please describe safety precautions:
What Support Would Be Helpful?
Select all that apply:
Companionship/conversation
Games/cards/puzzles
Arts and crafts
Reading
Current events / Daily Chronicle
Music / Sing-alongs
Baking / Cooking activities
Large-motor activites
Dementia-friendly activities
Technology assistance
Walks
Meal prep
Mealtime companionship
Light tidying related to the visit
Personal care assistance
Dressing / grooming assistance
Toileting assistance
Mobility asssistance
Routine reminders
Pet companionship / care
Respite companionship
Other
The Person Behind the Care
What does the client enjoy doing?
Favorite music/artists:
Favorite TV shows/movies:
Favorite games:
Favorite foods/snacks:
Topics they enjoy talking about:
Past career, accomplishments, family traditions, or life experiences they enjoy sharing:
Things they dislike or prefer to avoid:
What does a really good day look like for this person?
Is there anything else you want us to know that would help us make visits comfortable, meaningful, and enjoyable?
Home Access
How will the team member enter the home?
Client / family will answer
Facility staff
Key
Lockboxion 4
Other arrangements
Special parking or entry instructions:
For security, sensitive access codes may be collected separately rather than through this form.
Acknowledgment
Please acknowledge
*
I certify that the information provided is accurate to the best of my knowledge. I understand that I am responsible for notifying The Social Age of changes that could affect the safety or appropriateness of services.
Form completed by
First Name
Last Name
Today's date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
Continue
Continue
Should be Empty: