Homecare Intake Form - Senior Care
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1HOMECARE INTAKE FORM
Email Confidentiality Notice: The information contained in this form is privileged and confidential and/or protected health
information and may be subject to protection under the law, including the Health Insurance Portability and Accountability Act of
1996, as amended (HIPAA). Please fax this form to 978-282-1912 with an appropriate cover sheet.
When anticipating discharge from a facility, do not submit without a firm discharge date.
Gray sections are optional, all other sections are required.
FORM COMPLETED BY:
NAME & TITLE:
PHONE:
ADDRESS:
EMAIL:
FAX:
DATE COMPLETED:
RELATIONSHIP TO CONSUMER:
CONSUMER INFORMATION:
NAME:
PHONE:
ADDRESS:
DOB:
ALERT & ORIENTED:
YES
NO
LIVES ALONE:
YES
NO
MARITAL STATUS:
S
M
W
D
HOUSING TYPE:
OWNS
RENT
HOUSE
CONDO
APT
HOUSING AUTHORITY:
SMOKES:
YES
NO
CATS:
YES
NO
CONSUMER’S EMERGENCY CONTACT
NAME:
PHONE:
ADDRESS:
RELATIONSHIP TO CONSUMER:
HEALTH INSURANCE:
MEDICARE:
YES
NO
MASSHEALTH:
YES
NO NUMBER:
PCP NAME:
PCP PHONE:
HOSPITAL ADMISSION IN LAST 90 DAYS?
YES
NO
WHERE:
DATES:
REASON FOR ADMISSION:
REHAB AFTER HOSPITAL:
YES
NO
WHICH FACILITY:
DISCHARGE DATE:
VNA:
YES
NO WHICH VNA?
MEDICAL HISTORY (may include discharge summary/meds):
IS CONSUMER AWARE OF THE REFERRAL?
YES
NO
IF NO, WHY NOT?
CALL THE CONSUMER TO COMPLETE REFERRAL?
YES
NO
IF NO, WHOM SHOULD WE CONTACT?
NAME:
PHONE:
RELATIONSHIP:
SERVICES REQUESTED:
HM
HDMs
PC
MEAL PREP
MONEY MGMT
LAUNDRY
SHOPPING
COMPANION
FAMILY CAREGIVER SUPPORT GROUP?
YES
NO
OPTIONS COUNSELING?
YES
NO
Please attach additional comments, as appropriate
SENIORCARE HOMECARE INTAKE FORM (REV 05-25-2017)
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