1

Demographics & PHI

Staff-only form. Collect client identifying information and assign client code.

Client Intake Form
2

Acknowledgements & Authorizations

HIPAA Notice

Privacy practices

PHI Authorization

Storage & electronic signatures

Client Rights

Rights & responsibilities

Consumer Notice

Employment status notice

Service Agreement

Terms & authorization for care

Financial & Legal Restrictions

State regulations acknowledgment

3

Intake Forms & Assessments

All About Me

Person-centered profile

Functional Assessment

Task codes 115-141

Environmental Assessment

Home safety checklist

Home Visit

Safety evaluation info

New Client Information

Comprehensive intake form

Welcome Letter

Initial outreach letter

How to use this page

  • • Send forms to clients in order (1 → 2 → 3)
  • • Each link opens in a new tab for easy copying/sending
  • • Use for one-off clients who need specific forms