CareKey Partners – Family Intake

CareKey Partners – Family Intake

Welcome! Tell us a little about what's happening and where you could use support so we can prepare for our first conversation. CareKey provides non-clinical coordination in Greater Pittsburgh, including support for families who live elsewhere. This form is not monitored for emergencies. If someone is in immediate danger or needs emergency help, call 911. Please do not include diagnoses, medical records, or ID numbers.
Who is this support for?
Name of the person needing support

First NameLast Name
Your name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Your phone number
Please enter a valid phone number.Format: (000) 000-0000.
Your email address
example@example.com
Approximate age of the person needing support
Your name (person to contact)

First NameLast Name
Primary contact relationship to the person needing support
Your phone number (person to contact)
Please enter a valid phone number.Format: (000) 000-0000.
Your email address (person to contact)
example@example.com
Where is the person right now?

Other
Where are you currently staying?

Other
Facility name
What’s happening right now?

Other
Expected discharge/transition date (if applicable)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
What support or services are already in place?

Other
What do you need help coordinating?

Other
What are you most concerned about right now?
Please don't include diagnoses, medical records, or ID numbers.
Best time to contact
Anything else you’d like us to know?
Please don't include diagnoses, medical records, or ID numbers.
CareKey - Situation Score
CareKey - Timing Score
CareKey - Needs Score
CareKey - Support Gap Score
Follow-up Priority Score
CareKey - Location Score
CareKey Priority
CareKey Priority: URGENT
CareKey Priority: HIGH
CareKey Priority: MODERATE
CareKey Priority: ROUTINE
Best way to contact you
Non-Clinical Disclaimer: CareKey Partners LLC provides non-clinical care coordination and transition support. We do not provide medical advice, diagnosis, or treatment. Submitting this form does not establish a client relationship or authorize CareKey Partners to contact healthcare providers on your behalf.
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