Client Intake Form

Please indicate any and all medical conditions related to your care including injuries, allergies, behavioral health needs, recurring symptoms, surgeries, hospitalizations, and a list of current medications.

This information helps us understand your needs and match you with a properly qualified independent provider.

Please briefly describe your current care needs or goals you would like to focus on.

Please indicate if you need assistance in any of the following areas.

If Hygiene Care is needed, please specify:

Do you currently receive help in your home (e.g. family member, paid home health worker)?

How many days per week?

How many hours per day?

What type of services are you interested in?

REQUESTED SCHEDULE & AVAILABILITY

Please select your preferred days and times for support:
Note: Requested schedules are subject to provider availability and registry matching.

Identification and Insurance (Required)*

Drop files here or

Max. file size: 512 MB.

Please upload a copy of your driver’s license or state ID card, as well as your Medicaid or commercial insurance card, to verify your identity and benefits.

Past Documentation and Medical Records (Optional)

Drop files here or

Max. file size: 512 MB.

You can use this field to upload any relevant medical records, behavioral assessments, personal support plans, or documentation to assist with your care. This is completely voluntary and is not required. You can also have your healthcare provider share your medical records by completing the Medical Record Release Form.

CLIENT INTAKE FORM

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