Care Request Form
Please complete this form to request care services. Preserve the original questions and sections as closely as possible.
Requester Information
Full Legal Name
*
First Name
Last Name
Street Address
*
Apartment / Unit
City
*
State / ZIP
*
Phone Number (Person Requesting Care)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address (Person Requesting Care)
*
example@example.com
Are you 18 years of age or older?
*
Yes
Preferred method of contact
*
Phone
Email
Text
Completing Party / Authorization
Who is this form being completed for?
*
Myself
Someone Else
Name (Person Completing This Form)
First Name
Middle Name
Last Name
Relationship to Person Needing Care
Phone Number (Person Completing This Form)
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address (Person Completing This Form)
example@example.com
Are you authorized to discuss care arrangements for this individual?
Yes
Care Services and Scheduling
Care Being Requested - Services
*
Personal Care
Grooming / Personal Hygiene
Toileting Assistance
Transfer Assistance
Companionship
Meal Preparation
Medication Reminders
Light Housekeeping
Mobility Assistance
Other
When would you like care to begin?
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Days care may be needed
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Preferred Shift(s)
*
Morning
Afternoon
Evening
Overnight
Approximate hours of care needed per day
*
Days per week
*
Overnight care needed?
*
Yes
No
Weekend care needed?
*
Yes
No
Additional scheduling information
Care Needs and Home Environment
Does the person need assistance walking?
*
Yes
No
Does the person need assistance transferring (bed, chair, toilet, etc.)?
*
Yes
No
Is a wheelchair, walker, cane, or other mobility device used?
*
Yes
No
Is memory loss, dementia, or cognitive impairment relevant to the requested care?
*
Yes
No
Is assistance with eating needed?
*
Yes
No
Are there any safety concerns our team should know about when discussing potential services?
*
Yes
No
If yes to any of the above, please provide any information you would like us to know
Does the person live alone?
*
Yes
No
Are there pets in the home?
*
Yes
No
Are there stairs in the home?
*
Yes
No
If the person does not live alone, who lives in the home?
Is anyone currently providing care?
*
Yes
No
Current care provider
Please Select
Family
Friend
Another Agency
Other
Payment and Referral Information
How do you expect to pay for services?
*
Private Pay
Long-Term Care Insurance
Medicaid / Waiver Program
Other
Not Sure / Would Like to Discuss Options
Other payment source
Primary / Emergency Contact Name
*
First Name
Middle Name
Last Name
Primary / Emergency Contact Relationship
*
Primary / Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Primary / Emergency Contact Alternate Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Tell us about your care needs
How did you hear about us?
Family / Friend
Healthcare Provider
Hospital / Rehabilitation Facility
Social Media
Google / Internet Search
Other
How did you hear about us? - Other
Client Authorization and Signature
Name of Client or Authorized Representative
*
First Name
Middle Name
Last Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Relationship to Client
Signature
Signature Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Internal Intake Review
Inquiry Received Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Received By
First Name
Middle Name
Last Name
Initial Contact Completed
Yes
Consultation Scheduled
Yes
Consultation Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Service Area Verified
Yes
Requested Services Within Scope
Yes
No
Pending
Payment Source Discussed
Yes
Assessment / Intake Required
Yes
Proceed With Intake
Yes
Administrative Notes
Administrator / Reviewer Name (Print)
First Name
Middle Name
Last Name
Administrator / Reviewer Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Administrator / Reviewer Signature
Administrator / Reviewer Signature Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
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