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Senior Services Intake Form

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Steps

1. Information on Person Needing Services(current) This section is complete This section is incomplete
2. Services Requested This section is complete This section is incomplete
3. Name of Person Completing Intake Form This section is complete This section is incomplete

Information on Person Needing Services

First Name*
Last Name*
Address*
City*
State*
Zip*
County*
Email Address
Last 4 Digits of SSN*
Language
Date of Birth*
Home Phone Number*
Cell Phone Number
Marital Status
1. Married
2. Single
3. Widowed
Gender
1. Female
2. Male
Approximate Income Per Month
1. Over $1005
2. Below $1005
Race
1. Black
2. White
3. Native American
4. Other
Name of Emergency Contact
Phone Number
Client's Current Health Problems*
Client's Perception of Well-Being (Happy, Sad, Forgetful, Confused, etc.)
Continue

Services Requested

Please Select Which Services You Would Like to Receive
Congregate Meals
1. Yes
2. No
Home Delivered Meals
1. Yes
2. No
Is the Client Homebound?
1. Yes
2. No
Is There Someone Living With the Client Who Can Prepare Their Meals?
1. Yes
2. No
Level I In Home Aide
1. Yes
2. No
Level II In Home Aide
1. Yes
2. No
Transportation
1. General
2. Medical
Can the Client Complete the Following Tasks?
1. Prepare Meals
2. Shop for Personal Items
3. Manage Own Medications
4. Use Telephone
5. Do Light Cleaning/Housework
6. Drive
1. Eat/Feed themselves
2. Get Dressed
3. Bathe Self
4. Use the Toilet
5. Transfer into/out of bed/chair
6. Walk without help
Does the Client Live Alone?
1. Yes
2. No
Is the Person Living With the Client Able to Assist With the Client's Care?
1. Yes
2. No
If No, Why?
Does the Client Have Support From a Caregiver That Does Not Live With Them, Such as a Neighbor, Friend, or Family Member?
1. Yes
2. No
If So, Who?
Is the Client Currently Receiving Any Other Services?
1. Home Health Nursing/PT/ST/OT
2. CAP
3. Hospice Care
4. Other
Please List the Other Services.
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Name of Person Completing Intake Form

First Name*
Last Name*
Home Phone Number*
Cell Phone Number

Leave This Blank:

1. Receive an email copy of this form.
Email address

This field is not part of the form submission.
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