Free home care client intake form

Use it on the phone inquiry and finish it at the in-home assessment. Everything on it feeds the care plan, the schedule and the first invoice.

Read the guide

Agency:

Client intake form

Contacts

Client name Date of birth Phone Address Entry instructions Responsible party Phone Emergency contact 1 Phone Emergency contact 2 Phone Physician Pharmacy

Payer

Private payLong-term care insuranceMedicaid or waiverVAOther

Policy or ID number Authorized hours Deposit required $

Needs

Assistance levels: I = independent, S = standby or cueing, P = partial, F = full

Need	Level or detail
Bathing
Dressing
Toileting
Transfers and mobility
Eating
Memory
Fall history
Diet
Allergies
Medication reminders
Household tasks (IADLs)

Home

PetsSmokingStairsParkingWalkerShower chairOther equipment

Hazards

Preferences

Caregiver gender Language Routines, likes and dislikes

Schedule

Start date Minimum visit length

Day	Start	End	Hours

Documents signed before the first visit

Service agreementClient rightsPrivacy noticeInformation releasesCare plan

Completed by Date

When does intake have to be finished?

Before the first visit. Most agencies screen on the phone the day of the inquiry, complete the in-home assessment and signatures within two to three days, then write the care plan and brief the matched caregiver before care starts. Check your state's licensing rules for any required timeline.

How Caregiver Scheduling handles this

The schedule section goes straight onto the calendar as recurring visits, and the client's address puts them on the map next to the caregivers who already work nearby. See scheduling on the map.

These free tools are made by the team behind Caregiver Scheduling, caregiver scheduling software for home care agencies.

Simple pricing

From $199 /month

Up to 10 caregivers on Starter, 50 on Growth.

More than 50 caregivers? We'll put together a custom Scale plan for your agency.

Book my demo See pricing