The Senior Resource Network - Referral and Placement Advisors

Consumer Reviews for Senior Services

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Client Intake Assessment Form

Please fill out as completely as possible

Responsible Party Contact Information:
Name:	Relationship:
Home Phone:	Work Phone:
Cell Phone:	Email:
Address:	Preferred Method of Contact:
Client Information:
Client Name:	Sex:
Phone:	Marital Status:
Email:	Age:
Present Location:	Height:
Address:	Weight:

Preferred Location:	Anticipated Move Date:
Referral Source:	Working with another referral service?
Facilities already viewed or referred?	Care Setting Preference:	Adult Foster Care Assisted Living Alzheimer / Dementia Care Retirement Community Skilled Nursing Facility
Finance Options:	Interested in Private Case Management Services?	Yes No

Eating:	Dressing Ability:
Bathing / Grooming:	Night Care:

Check all that apply:

Toilet / Continence: Independent Minimum Assistance Moderate Assistance Maximum Assistance Dependent Bowel Incontinence Bladder Incontinence	Mobility / Transfers: Independent Minimum Assistance Moderate Assistance Maximum Assistance Dependent Wheel Chair Front wheel walker Cane	Behavior Management: No Behaviors Depressed Verbally Aggressive Physically Aggressive Anxious Refuses Care
Communication: Hearing Aids Glasses Non-English Speaking	Cognition: Alert Oriented to Self Oriented to Place Oriented to Family Oriented to Time Short Term Memory Loss Long Term Memory Loss	Nursing Care: IV's Tube Feeding Ventilator PT/OT/ST/RT Dialysis DM/SS Insulin Coumadin/ProTime
Medications: Psychoropic Anti-Depressant Anti-Anxiety Sleeping Meds Oxygen Med Management Pain Meds	Dietary Needs: Special Diet Vegetarian Lactose Intolerant DM Diet NAS / Salt Poor Appetite Ensure / Boost	Pets: Have Cat Likes Cats Dislikes Cats Allergies to Cats Have Dog Likes Dogs Dislikes Dogs Allergies to Dogs
Children: Likes children Rather not be around children Misc: Smoker Drink Alcohol	Religious Preference: Catholic Jewish Christian Muslim Bahia	Activity Needs: Social Outgoing Reserved Tends to isolate Enjoys games Enjoys outings Enjoys structured activities Has strong support system Has minimal support system

Current Diagnosis / Significant Medical History:

Any other comments or questions?