Intake Aging In Place

This form will help us understand your needs and preferences so we can best assess your goal of living independently in your own home. All information provided will be kept confidential.

In-Home(Aging In Place) Consultation Intake Form

Current Living Situation & Goals

What type of home do you currently live in? * ? (e.g., single-family house, condo, apartment)

Who else, if anyone, lives in the home with you? * ? (e.g., spouse, adult child, roommate)

Are you currently receiving any in-home assistance? *? If yes, please describe (e.g., family caregiver, paid caregiver, meal delivery):

Primary Contact / Responsible Party Information
(If different from Senior client, or if senior client needs assistance with decision-making)

Are you legally authorized to make decisions for the client? * ? If yes, please specify (e.g., Power of Attorney, Guardianship)

Health & Medical Information

Have you had any recent hospitalizations or emergency room visits? * ? If yes, please describe:

Have you experienced any falls recently? * ? If yes, please describe:

Do you have any cognitive concerns (e.g., memory issues, difficulty concentrating)? * ? If yes, please describe:

Do you require assistance with any of the following Activities of Daily Living (ADLs)? * ? (Please check all that apply and indicate level of assistance: Independent, Some Assistance, Full Assistance)

Do you require assistance with any of the following Instrumental Activities of Daily Living (IADLs)? * ? (Please check all that apply and indicate level of assistance: Independent, Some Assistance, Full Assistance)

Do you use any specialized medical equipment? * ? (e.g., oxygen, wheelchair, walker)

Are there any current behavioral issues or wandering concerns? * ? If yes, please describe:



Home Environment & Safety

Are there any areas in your home that feel unsafe or difficult to navigate? *? (e.g., stairs, slippery floors, poor lighting)

Is your home accessible for mobility devices if needed in the future? * ? (e.g., wider doorways, ramps)



Social Engagement & Support
Financial Information

This section is optional, but answers will offer a more accurate assessment

What is your approximate monthly income? ? (e.g., Social Security, pension, investments)

What financial resources are available for in-home care services or home modifications? ? (e.g., savings, long-term care insurance, reverse mortgage)

Do you have long-term care insurance? ? If yes, please list provider and policy number:

Are you eligible for or currently receiving any government benefits? ? (e.g., Medicaid, VA Aid & Attendance, Medicare Advantage plans with in-home support benefits)



Goals & Expectations

What specific support or services are you interested in exploring to help you stay in your home? ? (e.g., caregiver assistance, meal delivery, transportation, home modifications, medical equipment)

Senior Client Information

Veteran Status * ? If yes, branch and dates of service

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Thank you for reaching out. We know how important these care decisions are for your family. One of our Senior Care Experts will review your message and call you within 24 hours to discuss how we can help. In the meantime, you can find our Family Video Guides Here.
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