Intake Form Assisted Living

This form is designed to gather information to help us understand your needs and preferences, and to guide you in making informed decisions about assisted living options. All information provided will be kept confidential.

Assessment for Assisted Living Facility Referral

Current Living Situation & Needs

What is the client's current living situation? * ? (e.g., living alone, with family, independent living community)

What prompted the consideration of an assisted living facility? * ? (e.g., recent fall, increasing difficulty with daily tasks, loneliness, caregiver burnout)

What are the primary concerns or challenges the client is currently facing? *? (Please describe in detail)

Primary Contact / Responsible Party Information

If different from client, or if 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

List any current medications. *? (including over-the-counter and supplements)

Does the client have any allergies? *? (medication, food, environmental)

Does the client have a history of falls? *? If yes, please describe:

Does the client have any cognitive impairment? *? (e.g., dementia, Alzheimer's) If yes, please describe the stage/severity:

Does the client 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)

Does the client 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)

Does the client require any specialized medical equipment? *? (e.g., oxygen, wheelchair, walker)

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

Financial Information & Preferences

What is the client's approximate monthly income? ? (e.g., Social Security, pension, investments)

What financial resources are available for assisted living? ? (e.g., savings, long-term care insurance, sale of home)

Does the client have long-term care insurance?? If yes, provider and policy number:

Is the client eligible for or currently receiving any government benefits?? (e.g., Medicaid, VA Aid & Attendance)

Lifestyle & Preferences

Are there any specific dietary needs or preferences? ? (e.g., diabetic, vegetarian, low-sodium)

Does the client have any pets? ? If yes, type and size:

What is the client's preference regarding the size of the community? ? (e.g., small, medium, large)

What is the client's preference regarding location?? (e.g., near family, quiet area, urban setting)

What types of activities or amenities are important to the client?? (e.g., religious services, exercise classes, social events, library)

Goals & Expectations
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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