Referral & Intake Request Form

Full Name(Client's) *

Date of Birth(Client's) *

Gender(Client's) *

Address *

“Which county will services be provided in? (This helps us connect you with the appropriate Support Services Coordinator for your area.)? *

Phone Number *

Email address *

Emergency Contact Name *

Relationship to Client *

Emergency Contact Phone Number *

How many hours of care are you requesting each week, and on which days? *

Care Needs: Does the client need assistance with any of the following? (check all that apply) *

Bathing
Dressing
Grooming
Meal Preparation
Feeding Assistance
Toileting
Mobility Assistance (e.g., walking, transfers)
Housekeeping (e.g., light cleaning, organizing)
Laundry
Shopping (e.g., groceries, supplies)
Errands (e.g., picking up prescriptions, post office)
Transportation
Companionship (e.g., conversation, engaging activities)
Pet Care
Other - please provide in the comment field before submitting the form.

Client Preferences: To ensure the client’s comfort and well-being, please let us know any personal preferences or habits. Preferred routine or daily schedule (e.g., preferred times for meals, baths, activities) *

Does the client have any hobbies or activities they enjoy? *

Yes (please describe in the comment below)
No

Hobbies

Preferred activities or interests for caregiver to assist with *

Reading
Walking
Socializing
Arts and Crafts
Watching TV/Movies
Playing games or puzzles
Gardening
Other (provide in comment at the end)

Does the client have any specific preferences for caregiver appearance, behavior, or mannerisms? *

Yes (please describe) - describe in comment below.
No

If "Yes" was selected above

Social & Emotional Well-Being Understanding the client’s social and emotional needs helps us provide better support. Does the client enjoy regular social interaction?

Yes (please describe in comment space below)
No

If "Yes" was selected above

Does the client prefer to have a quiet environment or enjoy more interaction?

Quiet environment
More interaction
No preference?

Is the client open to having a caregiver in their home for companionship?

Yes
No

Living Environment - Please provide information about the client’s living situation and any relevant details about their environment. Is the client living alone?

Yes
No (if no, please provide details of who they live with):

If "No" was selected

Does the home have any special needs or concerns? *

No
Yes (please specify)

If "Yes" was selected

Does the client have any pets?

Yes (please describe)
No

If "Yes" was selected

Caregiver Preferences - We strive to match caregivers with clients based on compatibility. Please specify any caregiver preferences below.

Male
Female
No preference

Preferred caregiver language(s):

Preferred caregiver age group (e.g., young adult, senior, etc.):

Other preferences for caregiver characteristics (e.g., patient, friendly, energetic):

If you are a parent/guardian filling out the form, are you working with an organization? If so, can you please provide the name of the organization along with the information(Name, email and phone number) for the Case Manager?

Anything else?

Signature of Client or Representative
By signing below, you confirm that the above information is accurate and complete to the best of your knowledge.

Client or Representative Name *

Signature or Name (It can be Case Managers, Parents/Guardians, etc.,) *

Date *

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Referral & Assessment Form

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