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Intake Form

Intake Form

This form will help us design a Care Plan for your loved one, Please complete in as much detail as possible.

It is understandable that at times like this it may be difficult to complete such, and it is ok to do your best and we can help out from there.

If you have any questions Please call (902)334-5427

Client Intake Form

Today's Date*

Rate of Pay

ALERTS

HEALTH ALERT*

MOBILITY ALERT*

DNR / ADVANCED DIRECTIVE ALERT*

BEHAVIOUR ALERT*

Client Information

Client's First name*

Client's Last name*

Client's Phone Number

Client's Physical Address*

Client's Age*

Client's Birthday

Year

Month

Day

Client's MRN Number

EMERGENCY CONTACT

Client's Emergency Contact*

Emergency Contact Phone Number*

Emergency Contact's Email

Medical

List All Medical Conditions for the Client?*

Does the Client Have a DNR or Advanced Directive and where is it kept?*

Do our staff have to help with Medication Administration?*

Please have a List of Medications on arrival.

Where are the medications kept?*

Mobility

Mobility*

Independant

Needs Staff assistance

Cane

Walker

Wheelchair

Bedridden

Dietary

Does the Client needs Meals Prepared for them?*

Does the Client needs Meals Prepared for them?

Do they prepare some of there own meals, do they have meals on wheels, do family supply meals, do you need our staff to prepare meals?

Is there any dietary restrictions?

What Foods does the Client Like?

What foods does the Client Dislike?

Meal Plan

Routines

Toileting Routine

Shower Routine

Morning Routine*

Afternoon Routine*

Evening Routine*

Bedtime Routine*

What does getting they ready for bed look like?

Night Routine*

This is overnight (sleep pattern, are they up etc.)

Behaviour

What are the Client's Like's?

What are the Client's Dislikes?

What are the Clients Behaviours?*

What are some techniques to help deescalate a behaviour?

What are some of the Client's Triggers?

Activities of Daily Living (ADL's)

Tasks you would like staff to help out with?

Dishes

Laundry

Bed Changes

Garbage's Out

Sweeping

Mopping

Outings

Do you want our staff to do outing with the client.*

Please Note outings may be subject to mileage being charged.

General

General Notes*

ADMINISTRATION

What Type of Service are you looking for?*

Non-Urgent Medical Transport

Home Care

Socialization

Companionship

One on One Employment Preparedness

Other

How do Staff Enter the Home *

Are there any Pets on the Property?

Yes

No

Dogs

Cats

Birds

Fish

Staff Prefrence

We do Not have a Preference - Someone Good with our loved one.

Female

Male

English

French

Medical Based

Human Serviced Based

Behaviour Based

Other

PLEASE NOTE: We can not guarantee a schedule if you have preference's. I will do my best to fill your requests but can not guarantee coverage. I can make sure we only send your preference's. (For Example if you request female only, if we have a sick call we may only have a male available {Vice Versa})

Who is Responsible for Payment*

Client

Family

AAS

FA

Other

Name of Person completing Intake Form*

Signature (If your able)

Sign in the box or use the keyboard to type.

Signature field is empty.

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