CLIENT INTAKE FORM

Client Name: ___________________________________
Date of Birth: _____________ Gender: ____________
Phone Number: _________________________________
Address: ________________________________________
City: ________________ Postal Code: ______________
Emergency Contact Name: _________________________
Relationship: _______________
Phone Number: _________________________________
Health & Safety Information:
- Allergies: ____________________________________
- Medications (if any): ___________________________
- Mobility aids used: _____________________________
- Memory concerns or fall risk? [ ] Yes [ ] No
- Other medical conditions or relevant history: _____________________
Support Services Requested (check all that apply):
[ ] Appointment accompaniment
[ ] Errand running / Shopping
[ ] Light housekeeping / Organization
[ ] Friendly companionship
[ ] Tech help (phones, TV, emails)
[ ] Medication reminders (non-medical)
[ ] Other: ____________________________________
Home Access & Safety Notes:
- Lockbox code or key instructions: ________________
- Are there pets in the home? [ ] Yes [ ] No - Type: ________
- Parking instructions / buzz code: ________________
- Any known safety concerns? ____________________
Preferred Service Days/Times: _____________________
Preferred Contact Method: [ ] Phone [ ] Text [ ] Email
Additional Notes or Preferences:
_________________________________________________
_________________________________________________
Signature of Client or Representative: ___________________________
Date: ___________________