Intake form

This form is designed to assess a senior client’s ability to continue living independently in their own home, taking into account various aspects of their life. The information provided will be kept confidential.

Consultation Intake Form

Current Living Situation & Goals

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

How long have you lived at your current address? *? (e.g., 6 months, 2 years, 15 years)

Who else lives with you in your home? *? (e.g., spouse, adult child, roommate, caregiver)

Why do you want to continue living in your current home? *? (e.g., like the neighbourhood, want to stay near friends, home feels safe)

Do you have any concerns about living at home? *? (e.g., stairs are difficult, fear of falling, safety at night)

Do you currently receive any in-home assistance? *? (e.g., daughter visits daily, paid caregiver twice a week, meal delivery service)

Health & Medical Information

Please list your current medical diagnoses or conditions? *? (e.g., diabetes, high blood pressure, arthritis)

Please list all medications you are currently taking (including over-the-counter and supplements). *? (e.g., Metformin 500 mg, Vitamin D supplement)

Do you have any allergies? (medication, food, environmental) *? (e.g., penicillin, peanuts, pollen)

Have you had any recent hospitalizations or emergency room visits? *? (e.g., admitted for pneumonia last month, ER visit for chest pain in June)

Have you experienced any falls recently? *? (e.g., slipped in bathroom last week, two falls in the past six months)

Do you have any cognitive concerns? *? (e.g., memory issues, difficulty concentrating, confusion)

How much assistance do you currently need with Activities of Daily Living (ADLs)? *? (e.g., bathing, dressing, toileting, eating, transferring, continence)

How much assistance do you currently need with Instrumental Activities of Daily Living (IADLs)? *? (e.g., meal preparation, housekeeping/tidying, managing medications, transportation, shopping, using telephone/technology, managing finances)

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

Do you have any behavioral or wandering concerns? *? (e.g., restlessness at night, tendency to leave home, aggressive behavior)

Home Environment & Safety

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

Do you have safety features in your bathroom? * ? (e.g., grab bars near toilet or shower, non-slip mats)

Is your home accessible for mobility devices? * ? (e.g., wider doorways, ramps, stair lifts)

Are your smoke and carbon monoxide detectors working? * ? (e.g., tested monthly, replaced batteries recently)

Do you have a personal alert system in case of emergencies? * ? (e.g., Medical Alert, wearable emergency button)

How is your home maintenance and repairs managed? * ? (e.g., family member does repairs, hire professionals, some repairs unmet)

Do you feel safe in your neighborhood? * ? (e.g., yes, mostly; no, due to crime or lighting issues)

Social Engagement & Support

How often do you interact with family, friends, or neighbors? * ? (e.g., daily, weekly, rarely)

Do you feel socially connected? * ? (e.g., yes, very connected; somewhat connected; not connected at all)

Are you involved in any social groups, clubs, or religious organizations? * ? (e.g., church group, local club, senior center, volunteer group)

Who would you contact in an emergency? (Please list emergency contacts) * ? (e.g., spouse, adult child, neighbor, friend)

Do you have reliable transportation for appointments, errands, and social activities? * ? (e.g., personal car, public transit, rides from family, community transport service)

Financial Information

What is your approximate monthly income? ? (e.g., $1,200/month from Social Security and pension)

Do you have financial resources available for care or home modifications? ? (e.g., savings, long-term care insurance, reverse mortgage)

Do you currently have long-term care insurance? If yes, please describe. ? (e.g., policy covers in-home support up to $150/day)

Do you receive or qualify for any government benefits? ? (e.g., Medicaid, VA Aid & Attendance, Medicare Advantage in-home support benefits)

Goals & Expectations

What types of support or services are you interested in exploring? * ? (e.g., caregiver assistance, meal delivery, transportation, home modifications, medical equipment)

What are your primary goals for this assessment? * ? (e.g., stay in my home safely, reduce fall risk, get more help with daily activities)

Is there any additional information you’d like to share to help us better understand your needs? * ? (e.g., special preferences, family concerns, unique circumstances)

Client Information

Full Name of Client

Date of Birth

Current Address

Phone Number

Email Address

Preferred Language

Marital Status

Spouse's Name (if applicable)

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

Yes No

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