Patient Intake

Patient Intake Form

Thank you for considering our care services. This intake form helps us understand your needs so we can provide safe, personalized, and reliable in-home support.

Please complete the sections below as thoroughly as possible. The information you provide allows our care team to match you with the right caregiver, build an appropriate care plan, and respond quickly—especially for urgent situations.

All information is kept confidential and used only to coordinate your care.

If you need immediate assistance or prefer to speak with someone directly, please indicate below or contact us—we’re here to help.

Private Pay Elderly Care Intake Form

Step 1: Client Basic Information

Full Name Date of Birth Age Gender Address (Home location of care) Phone Number Email Address Preferred Contact Method

Step 2: Primary Contact / Responsible Party

Name Relationship to Client Phone Number Email Billing Responsibility (Yes/No) Power of Attorney (Yes/No) Emergency Contact (Yes/No)

Step 3: Emergency Contacts (Secondary)

Name Relationship Phone Number Alternate Phone Address

Step 4: Care Needs Overview

Reason for Care (checkboxes): Post-surgery recovery Dementia / Alzheimer’s Mobility issues General aging support Companionship Other (text) Level of Assistance Needed: Minimal supervision Moderate assistance Full assistance Start Date for Care Urgency: Immediate Within 1 week Planning ahead

Step 5: Activities of Daily Living (ADLs)

Rate each (Independent / Needs Help / Dependent): Bathing Dressing Toileting Transferring (bed/chair) Eating Continence

Step 6: Instrumental ADLs (IADLs)

Meal Preparation Medication Reminders Housekeeping Laundry Transportation Shopping / Errands

Step 7: Medical Information (Non-Clinical Overview)

Primary Physician Name + Phone Diagnosed Conditions Allergies Medications (list or upload) Fall History (Yes/No + details) Mobility Aids: Walker Wheelchair Cane None

Step 8: Cognitive & Behavioral Status

Memory Issues (None / Mild / Moderate / Severe) Diagnosis: Alzheimer’s Dementia None Orientation: Person Place Time Behavioral Concerns: Wandering Aggression Anxiety Depression

Step 9: Home Environment & Safety

Lives Alone (Yes/No) Type of Residence: House Apartment Assisted living Stairs in Home (Yes/No) Pets (Yes/No + type) Smoking in Home (Yes/No) Safety Concerns: Fall risks Clutter Poor lighting

Step 10: Schedule & Care Plan

Days Needed: Mon Tue Wed Thu Fri Sat Sun Hours Needed: Morning Afternoon Evening Overnight / 24hr Preferred Caregiver Gender (optional) Language Preferences Special Requests

Step 11: Payment Information (Private Pay Focus)

Payment Method: Credit Card ACH Check Billing Frequency: Weekly Bi-weekly Long-Term Care Insurance (Yes/No) Budget Range (optional): <$20/hr $20–$30/hr $30+/hr

Step 12: Service Agreement Acknowledgements

Understanding of non-medical care scope (checkbox) Cancellation policy agreement Minimum hours requirement Liability acknowledgment Signature (digital) Date

Step 13: Lead Source

How did you hear about us? Google Search Google Ads Facebook Referral Hospital / Facility Other Keywords searched (optional) Campaign / Promo Code

Step 14: Internal Use Only (Do NOT show publicly)

Lead Score Urgency Score Estimated Weekly Hours Estimated Monthly Revenue Assigned Care Coordinator Follow-up Date Status: New Contacted Assessment Scheduled Converted

Add-Ons (Optional) (optional)

Request Immediate Call Back (checkbox) Need care within 24 hours? (flag) SMS opt-in (checkbox) File upload (med list / discharge papers)

Patient Intake

Patient Intake Form

Private Pay Elderly Care Intake Form

Contact

Opening Hours

Useful Links