Intake Form

Full Name *

Date of Birth *

Gender *

Phone *

Current Living Situation *

Do you have any children or significant other that will be coming with you? *

How many children?

What are the ages of your children?

What is your anticipated move in date? *

Health & Medical Needs:

Medical Conditions

Are they on Medication?

If yes, please provide medication list.

Client Mobility Level (e.g., independent, requires assistance, wheelchair-bound):

Cognitive Status

Special Care Requirements

Social & Emotional Needs

Personality & Preferences

Client Family Involvement (e.g., guardianship, frequency of visits):

Cultural and Religious Considerations

Financial & Legal Information

Financial Situation *

Do you receive Social Security Disability Income? *

Client Source of Income (e.g., SSI, SSDI, employment, unemployment): *

Do you need assistance with finding work? *

Insurance Coverage

Legal Documentation

Desired Amenities & Services

Preferred Living Arrangement *

Ammenities

Location Preference

Safety & Security Concerns

Safety Needs

Emergency Prepardness

Additional Information

Previous Experiences

Staff and Caregiver Preferences

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