Quick Client Intake Form

Client Information

Client Name *

Preferred Language

Phone *

Email Address *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal code

Country

Preferred Method of Contact (Phone/Email/Text)

Emergency Contact Information

First Emergency Contact Name *

Phone *

Relationship to Client *

Second Emergency Contact Name

Phone

Relationship to Client

Services Requested

Please check all services being requested.

Why Are You Seeking Home Care? *

Medical Information

Primary Diagnosis

Other Medical Conditions

Allergies

Recent Hospitalization?

Recent surgery?

Functional Status

Can the client perform the following independently?

Safety Information

Falls in the last 12 months? *

Oxygen use? *

Smoking in the home? *

Aggressive behaviours? *

Dementia diagnosis? *

Wandering risk? *

Pets in the home? *

Infection control concerns (e.g., MRSA, C. difficile, COVID-19 history)? *

Communication barriers (hearing, vision, or speech impairment)? *

If yes to any of the above, please provide details

Care Schedule

Care is available in flexible 3 hour or longer visits, allowing our healthcare providers enough time to provide meaningful, personalized support rather than rushing through a short appointment. Care can be scheduled weekly, daily, evenings, weekends, overnight, or on an ongoing basis. Our 3 hour minimum allows our healthcare providers the time to do more than simply complete a task. It gives them time to provide personal care, companionship, meal support, light household assistance, mobility support, and meaningful interaction during each visit.

Services needed during: *MorningAfternoonEveningOvernight

Requesting Start Date *

Goals of Care

Please share your goals/expectations of care. *

Care Preferences & Additional Considerations

Who should caregivers report concerns to? *

Does the client have any cultural or religious preferences staff should be aware of? *

Preferred caregiver gender *

Client's hobbies or interests (especially valuable for companion care) *