INTAKE STEP 2 OF 2

Part 2: Client Profile

Complete online BEFORE your home visit

DE-IDENTIFIED

Your Client Code

Enter the client code you received during your phone intake. This keeps your information secure.

Client Code:

Date:

Don't have a code? Contact us at (800) 719-6912 to complete your phone intake first.

How to Address You

Preferred Name/Nickname:

Pronouns:

Preferred Language:

Preferred Method of Communication:

Phone Call Text Message Email

What Brings You to Us

1. In your own words, what kind of help are you looking for?

2. Type of Assistance Needed (check all that apply):

Personal Care (bathing, dressing) Household Support (cleaning) Meal Preparation Transportation Medication Reminders Errands/Shopping Companionship Mobility Assistance Supervision Other:

Requested Care Schedule

This helps us understand your needs. Final schedule will be confirmed during assessment.

1. Which days do you need care? (check all that apply)

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

2. What times do you need care?

1 Shift 1

Start:

End:

Days:

2 Shift 2 (if needed)

Start:

End:

Days:

3 Shift 3 (if needed)

Start:

End:

Days:

3. Schedule Notes

Any special scheduling considerations (e.g., flexibility, exceptions, recurring appointments)

4. When would you like to start?

Preferred start date:

Living Environment

1. Does anyone under 18 live in the home?

(Pennsylvania requires caregivers working in homes with minors to have child abuse clearances)

Yes No

2. Does the client live alone?

Yes No

3. Does someone else have a key to your home in case of emergency?

Yes No

We'll collect keyholder details during phone intake.

4. Does anyone smoke in the home?

Yes No

5. Are there pets in the home?

Yes – type(s): No

If yes, are the pets friendly with visitors?

Yes No

We ask that pets be secured or controlled during caregiver visits for everyone's safety.

6. Are there any specific safety concerns in your home (e.g., stairs, clutter, mobility obstacles)?

Yes – please describe: No

7. How should the caregiver enter your home?

Knock / Ring doorbell Keypad on door Lockbox Hidden key Door left unlocked Other

Entry details (code, lockbox location, special instructions):

Current Services & Equipment

Provider names and contact details are collected during phone intake.

1. Are you currently receiving any of the following services?

Skilled Nursing:

Yes No

Hospice:

Yes No

Wound Care:

Yes No

Physical Therapy:

Yes No

2. Do you use oxygen?

No Yes – continuous Yes – as needed / PRN

Anything Else?

Is there anything else you'd like us to know before your visit?

Email Form Link Call (800) 719-6912

Client Profile (De-Identified) | Version 2.0 | January 2025

This form contains no Protected Health Information (PHI)