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Customer Intake

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Customer Intake

To be completed by DHA coordinator and (or) supervisor.

ESD:

ASD:

Caller Information

Contacted by *

Phone
Email
Other

Name of Caller: *

Referral source: *

Phone Home: *

Work:

Cell:

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Caller Relationship to Patient: *

Spouse
Parent
Grandparent
Children
Proxy
Other

Please select the option that describes the individual or caller giving the intake details

If other

Please contact me by

Phone
Email

Please contact me in the

Mornings
Afternoons
Evenings

Information for Person Requiring Service:

Name *

First

Last

Age

Date of Birth://

Veteran or Spouse

Yes
No

Weight

Gender *

Male
Female
Other

If Other

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Service details

Q. Is care currently being provided? *

Yes
No

Care provided by:

Family
Friends
Medicaid
Insurance
Private
Vac

Q: Details of Current Care

Q: Details of Anticipated Need for Service *

CHHA
Companion
RN
VAC

Q: Services Required *

Immediately
Couple Weeks
Month
Unsure
Other

If Other

Q: How long will service be required? *

Payment and Billing Details

Billing Option *

Insurance
Private Pay
Other

If other

Q: Insurance Provider:

Member ID:

Group Number:

Is there family support in home? *

Yes
No

If yes: Name

Relationship

If No: Name of closes family support

Relationship

Functionality Status

(Check all that applies)

Mobility

Bedbound
Needs Assistance

Needs assistance with:

Ambulation
Transfers
Stairs

Assistive Devices

Walker
Cane
W/C
Shower/tub chair
Commode

ADL's and IADL's

Dressing
Bathing
Grooming
Oral Hygiene

Needs assistance with: (Check all that applies)

Personal care

Meal prep and cooking
Shopping
Cleaning

Transportation

Drives
Dependent on others

Vision

Glasses
Blind
Legally Blind

Hearing

HOH
Hearing Aids
NA

Ear Affected

Right Ear
Left Ear
Both Ear

Speech

Difficulty speaking
Does not speak
Does not speak or understand English

Alert/Awake/Oriented?

Yes
No

If no, explain:

Does client experience memory loss?

Yes
No
Confusion
Forgetfulness
Other

If other

Is client incontinent

Yes
No

If yes, of:

Urine
Bowels
Wears disposable undergarments

Physician Information

Q. Physician's Name *

First

Last

Office Address

Address Line 1

Address Line 2

City

State

Zip Code

Medications:

NOTES:

Results of the call

Consultation: Date / Time

Date

Time

Place:

Assessment

Nursing Assessment

Details

Assessment

General Assessment

Details

Next steps

Mail Info Package
Phone Follow-up
Phone Follow- up
phone Follow-up
Will Call Back
Not Interested

Mail sent date

Call Date

When

Date

Time

Why

Intake Coordinator's Name *

Date

Supervisor's Name *

FOLLOW UP NOTES

Signature

Date

Calendar

March 2023
M	T	W	T	F	S	S
		1	2	3	4	5
6	7	8	9	10	11	12
13	14	15	16	17	18	19
20	21	22	23	24	25	26
27	28	29	30	31

« Apr

Other Info

Customer Care
Job Application
Personal Chef Partners

Customer Intake

Caller Information

Information for Person Requiring Service:

Service details

Payment and Billing Details

Functionality Status

Physician Information

Results of the call

Recent Posts

Calendar

Other Info