Client intake form

Fill this out on your own before your visit, or together with your care coordinator on her tablet. Everything saves electronically, no paper packet needed.

Have these ready if you can

· Photo ID for the client
· Photo ID for the responsible party
· Current medication list
· Physician orders or discharge paperwork (if any)
· Insurance or payer card (if applicable)
· Power of attorney or guardianship papers (if applicable)
· Emergency contact list
· House key or entry instructions
· Signed care agreement
· Signed payment authorization

Client information

Who will be receiving care.

First name

Last name

Date of birth

Gender

Phone

Preferred language

Street address

City

State

ZIP

Responsible party and emergency contact

Contact name

Relationship to client

Contact phone

Contact email

Emergency contact name

Emergency relationship

Emergency phone

This contact makes care and payment decisions for the client.

Care requested

Check everything that applies. Nothing is final, the care coordinator will confirm at the assessment.

Companion carePersonal care (PCA)CNA level careRespite carePostpartum and newborn supportAfter school and child supportPet helpTransportation and errandsHomemaking and light housekeepingOvernight care

Daily help needed

Bathing and groomingDressingToileting and incontinenceTransfers and mobilityMedication remindersMeal preparationFeeding assistanceVital signsRange of motion exercisesMemory supportCompanionship and activitiesLaundry and linensGrocery shoppingAppointment transport

Preferred days

Preferred times

Hours per week

Requested start date

Goals for care

Health and home details

Share what you know. Blank answers are fine, the coordinator will fill the rest in at the visit.

Diagnoses and health history

Current medications

Allergies

Mobility and transfers

Memory, mood and behavior

Diet and nutrition

Home safety notes

Pets in the home

Physician name

Physician phone

Pharmacy name

Pharmacy phone

Payment

ClearPath Cares is private in home care. Online payment is preferred over cash.

How will care be paid for?

Payer or insurance notes

I understand ClearPath Cares is private pay, that a one time enrollment fee of $250 is due before care begins, and that invoices are sent and paid electronically.

Anything else

Notes for the care coordinator

Signature

Sign with a finger or stylus. This intake is stored electronically, no paper copy is needed.

Your full name

Relationship or role

Sign with your finger or stylus