Client Intake — Award HomeCare

Client Information

First name

Last name

Email

Phone

Address

City

State

ZIP

Date of birth

Marital status

Lives alone?

Spouse name (if applicable)

Primary Contact / POA

Name

Relationship

Phone

Secondary Contact

Name

Phone

Type of service

Caregiver preference

Car needed?

Type of care needed

Primary physician name

Physician phone

Wound care needed?

Feeding help

Veteran status

Veterans & spouses may qualify for up to $2,200/month toward in-home care.

Long-term care insurance

Has LTC insurance?

Insurance name

Policy number

Claim number

Food allergies

DNR?

DNR docs on file?

Languages spoken Pets (note: AHC does not provide pet care) Interests / hobbies Additional notes How did you hear about us?