CLIENT INTAKE FORM
License #241355
Date of Intake:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Start Date of Services:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
CLIENT INFORMATION
Full Name:
First Name
Last Name
Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender:
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
Format: (000) 000-0000.
Email (if applicable):
example@example.com
Preferred Language:
Primary Diagnosis (if applicable):
Allergies:
EMERGENCY CONTACT INFORMATION
Primary Emergency Contact
Name:
First Name
Last Name
Relationship:
Phone:
Format: (000) 000-0000.
Email:
example@example.com
Secondary Emergency Contact (if applicable):
Name:
First Name
Last Name
Relationship:
Phone:
Format: (000) 000-0000.
Primary Physician (if applicable):
Name:
First Name
Last Name
Phone:
Format: (000) 000-0000.
Back
Next
CLIENT TYPE (Check all that apply)
CLIENT TYPE (Check all that apply)
Elderly
Disabled Individual
New Mother (Postpartum Support)
Other
LIVING SITUATION
LIVING SITUATION
Living Alone
Living with Spouse
Living with Family
Assisted Living
Other
Are there pets in the home?
Yes
No
If yes, describe:
Are there any safety concerns in the home?
Fall risks
Stairs
Oxygen in use
Aggressive pets
Other
MOBILITY STATUS
MOBILITY STATUS
Independent
Uses Cane
Uses Walker
Wheelchair
Bed-bound
Needs Assistance with Transfers
History of Falls in the last 6 months?
Yes
No
If yes, explain:
PERSONAL CARE NEEDS
(For elderly and disabled clients)
Does client need assistance with:
Bathing
Dressing
Grooming
Toileting
Meal Preparation
Feeding
Back
Next
Services Requested
Light Housekeeping
Laundry
Transportation
Medication Reminders (non-administration only)
Additional Notes:
POSTPARTUM / NEW MOM SECTION (If Applicable)
Type of Delivery:
Vaginal
C-Section
Date of Delivery:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Is mother currently experiencing:
Fatigue
Postpartum Depression/Anxiety (diagnosed or suspected)
Physical recovery limitations
Limited family support
Baby Care Support Requested:
Newborn supervision
Feeding support (non-medical)
Light baby-related laundry
Night support
Household support
Additional Notes:
COGNITIVE STATUS
Cognitive Status Options
Alert and Oriented
Mild Memory Issues
Dementia/Alzheimer's
Developmental Disability
Other
Any history of wandering?
Yes
No
MEDICATIONS (Optional – for awareness only)
List medications (for reminder purposes only):
Note: Agency provides medication reminders only.
No medication administration.
SCHEDULE REQUEST
Back
Next
Days Needed:
Preferred Hours:
Total Hours per Week:
Is overnight care requested?
Yes
No
CLIENT GOALS
What are your primary goals for services?
Safety
Companionship
Recovery Support
Respite for Family
Independence at Home
Other
Additional Comments:
CONSENT & ACKNOWLEDGMENT
I certify that the information provided is accurate to the best of my knowledge. I understand that Better Life Home Care Agency provides non-medical services only and the client and or whoever is representing the client is liable for any and all medical related issues. I consent to receiving care from Better Life Home Care Agency.
Client/Representative Signature:
Printed Name:
First Name
Last Name
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Agency Representative:
First Name
Last Name
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preview PDF
Submit
Should be Empty: