Patient Information and Intake Form

Location *

Client Stage

Patient First Name *

Patient Last Name *

Patient Email / Point of Contact / Next of Kin Email *

Patient Type or Classification

CLTC#

Grant Options (if applicable)

Private Insurance Name

Additional Identification Number Type

Additional Identification Number

Patient ID / Social Security Number

Patient Best Phone Number *

Point of Contact Phone Number

Birth Date *

Patient Age

Street Address *

City *

State/Region/Province *

Postal / Zip Code

Gender *

Marital Status *

Service Information

Provider *

Personal Care Level of Service *

Procedure Code *

Care Hours Type

Total Hours Allotted

Total Service Hours Weekly

Service Day(s)

Service Hours Preferred Time

Personal Care Start Date

End Date (if applicable)

Termination Reason (if applicable)

Assigned Home Health Aide First Name

Assigned Home Health Aide Last Name

Nurse First Name *

Nurse Last Name *

Case Worker Information

Case Worker First Name

Case Worker Last Name

Case Worker Phone Number

Emergency Contact Information

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Address *

Emergency Contact Relationship *

Emergency Contact Phone Number

Other Information

Legal Status

Medical Contact Information

Primary Care Physician First Name

Primary Care Physician Last Name

Physician Telephone

Hospital Name and Address

Hospital Telephone

Specialist Physician First Name

Specialist Physician Last Name

Specialist Telephone

Specialist Hospital Name and Address

Specialist Hospital Telephone

Date Service Begin *

Initial Site Visit Date

90 Day Visit Date

60 Day Visit 1 Date

60 Day Visit 2 Date

Type of Visit *

Name of Admin Doing Intake - First Name

Name of Admin Doing Intake - Last Name

Date *

Signature — type your full legal name to sign *

I confirm the information above is accurate and I am electronically signing this form *