Elder Care Intake Form

This form will help us understand your needs and preferences so we can provide you with the best possible elder care consulting services. Please fill it out to the best of your ability. All information will be kept confidential.

Elder Care Consultant Intake Form

Current Living Situation

Where do you currently live? * ? If your situation isn’t listed, select ‘Other’ and type it in.

If no, what areas do you need assistance with? * ? If your situation isn’t listed, select ‘Other’ and type it in.

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 regarding financial/legal matters? * ? If yes, please specify (e.g., Power of Attorney, Guardianship)

Health Information

Are you currently receiving any home healthcare or other in-home services? * ? If yes, please describe:

Do you have any concerns about your memory or cognitive abilities? *? If yes, please explain:

Are you currently taking any medications (prescription or over-the-counter)? * ? If yes, please list them with dosage and frequency

Do you have any vision impairments? * ? If yes, please describe

Do you have any hearing impairments? * ? If yes, please describe

Are you able to communicate your needs effectively? * ? (If no, please explain)

Social and Emotional Well-being

Do you have a strong support system (family, friends, community groups)? * ? If yes, who are your primary support people?

Do you participate in any social activities or hobbies? * ? If yes, please list them

Do you experience feelings of loneliness, isolation, or depression? * ? If yes, please explain

Financial Information (Optional, but helpful for resource planning)

What is your primary source of income? * ? If your situation isn’t listed, select ‘Other’ and type it in.

Do you have health insurance? * ? If yes, what type? \Medicare \Medicaid \Private Insurance \ Other

Are you concerned about your ability to afford future care or living expenses? * ? If yes, please explain

Legal Information (Optional, but helpful for comprehensive planning)
Your Goals and Concerns
Client Information
Emergency Contact Information
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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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