Client Intake Form - Silver Home Care

1. CLIENT INFORMATION

Personal Information

Client Name

Date of Birth

Age

Gender

Contact Information

Primary Phone

Leave Message?

Yes No

Cell Phone

Can Text?

Yes No

Email Address

Can Email?

Yes No

Service Address

Street Address

City

State

ZIP

Township

County

2. CONTACTS & MEDICAL PROVIDERS

Primary Contact

Main person for day-to-day scheduling and routine care decisions.

Who is the primary contact?

Client Other

Full Name

Relationship

Phone

Email

Emergency Contact

Full Name

Relationship

Phone

Email

Medical Providers

Primary Doctor

Phone

Skilled Nursing

Phone

Wound Care

Phone

Hospice

Phone

Pharmacy

Phone

4. HOME INFORMATION

Home Type

Single Family Apartment Senior Housing Other

Living Situation

I live alone

If not, who lives with you?

Floor Level

First Floor Second Floor Other

Entry Instructions

Knock Buzzer / Doorbell Intercom / Call Box Lockbox - Code:

Where do we park?

Driveway On Street Parking Garage None Available

Pets

Yes, there are pets No pets

Pet Details (type, name, temperament)

Smoking

Yes, someone smokes No one smokes

5. PAYMENT & INSURANCE

Payment Source

CHC Veterans Private Pay LTC Insurance Other

MCO Name

MCO Member ID

Service Coordinator

Coordinator Phone

Medicaid ID

Medicare ID

Primary Insurance

Member ID

Client Profile

1. CLIENT INFORMATION

Personal Information

Contact Information

Service Address

2. CONTACTS & MEDICAL PROVIDERS

Primary Contact

Emergency Contact

Medical Providers

4. HOME INFORMATION

Home Type

Living Situation

Floor Level

Entry Instructions

Where do we park?

Pets

Smoking

5. PAYMENT & INSURANCE