This Client Intake Form template covers demographics, health history, and needs assessment. This template is structured to capture comprehensive client information for effective onboarding and personalized care. 

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Client Intake Form

Agency Name & Contact Information

Agency Name: Address: Phone Number: Email:

1. Client Personal Information

• Full Name: _____________________________________ Date of Birth: ________________________________
• Gender: _______________________________________  Social Security Number: ______________________
• Medicaid ID: ____________________________________ Primary Language: __________________________
• Contact Number(s): ______________________________ Email Address: _____________________________
• Address: __________________________________________________________________________________
• Emergency Contact Name: _______________ Contact Phone: _________Relationship to Client: _________

2. Client Representative Information (if applicable)

• Representative Name: _____________________________ Relationship to Client: ______________________
• Phone Number: ___________________________________Email Address: ____________________________
• Address: __________________________________________________________________________________

3. Demographics and Background

• Marital Status: ☐ Single ☐ Married ☐ Divorced ☐ Widowed
• Living Situation: ☐ Alone ☐ With Family ☐ Assisted Living ☐ Other: _____________
• Primary Care Physician: ____________________________ Physician Contact Information: ______________
• Religion/Spiritual Preferences (optional): ________________________________________________________

4. Health History

• Primary Diagnosis: ________________________________________________________________________
• Secondary Conditions: _____________________________________________________________________
• Allergies: ☐ None ☐ Yes (List): _______________________________________________________________
• Current Medications:

• Assistive Devices Used: ☐ None ☐ Cane ☐ Walker ☐ Wheelchair ☐ Other: ___________
• Physical Limitations or Impairments: ☐ None ☐ Yes (Describe): ___________________
• Dietary Restrictions: ☐ None ☐ Yes (List): _____________________________________
• Past Surgeries or Hospitalizations: ☐ None ☐ Yes (List): _________________________
• Mental Health Concerns (if any): ☐ None ☐ Anxiety ☐ Depression ☐ Other: __________
• History of Falls in the Past Year: ☐ None ☐ Yes, Number of Falls: __________________

5. Needs Assessment

• Assistance Needed With (check all that apply):
  • ☐ Bathing
  • ☐ Dressing
  • ☐ Toileting
  • ☐ Feeding
  • ☐ Mobility
  • ☐ Medication Management
  • ☐ Housekeeping
  • ☐ Transportation
  • ☐ Meal Preparation
  • ☐ Companionship
• Preferred Care Schedule: ☐ Full-Time ☐ Part-Time ☐ Overnight ☐ As Needed
• Additional Services Requested (e.g., physical therapy, nursing): ______________________________________

6. Communication Preferences

• Preferred Method of Communication: ☐ Phone ☐ Email ☐ Text ☐ In-Person
• Best Time to Contact: ☐ Morning ☐ Afternoon ☐ Evening

7. Insurance Information

• Primary Insurance Provider: _____________________________________ Policy Number: ________________
• Secondary Insurance (if applicable): ______________________________ Policy Number: ________________

8. Legal & Financial Information (Optional)

• Power of Attorney (POA) for Healthcare: ☐ Yes ☐ No
  • POA Contact Information: _________________________________________________________________
• Guardian Information (if applicable): ____________________________________________________________
• Advance Directives/Living Will: ☐ Yes ☐ No

9. Client Goals and Expectations

• Main Goals for Care (e.g., maintain independence, manage chronic conditions): ________________________________________________________________________________________________________________________________________________________________________________________________________________________________

• Client’s Personal Care Preferences: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

10. Signature and Consent

I, ____________________________________, confirm that the information provided above is accurate to the best of my knowledge. I authorize [Agency Name] to use this information for the purpose of providing care and support services.

Client/Representative Signature: _________________________________________ Date: _______________________

For Agency Use Only

• Intake Completed By (Staff Name): ____________________________________
• Date of Intake: _____________________________________________________
• Additional Notes: ___________________________________________________

This template captures critical data while maintaining a structured format that’s easy to follow. You can adapt sections as needed based on specific program or agency requirements. You may reach out to us for a more customized form based on your state specific regulation. Call 302.888.9172 or email licensing@waivergroup.com for assistance.