Client Intake & Service Assessment Form

Client Intake & Service Assessment Form

Section 1 — Agency Information
Agency Name:
Agency Address:
City / State / ZIP:
Phone Number:
Email Address:
Section 2 — Client Identification Information
Full Name:
Date of Birth:
Gender:
Male Female Other Prefer Not To Say
Government ID / SSN (if required):
Client ID (Internal Use):
Primary Language:
Phone Number:
Email Address:
Address:
Section 3 — Emergency Contact Information
Emergency Contact Name:
Relationship to Client:
Phone Number:
Alternate Phone:
Address:
Section 4 — Authorized Representative (If Applicable)
Full Name:
Relationship to Client:
Phone Number:
Email Address:
Address:
Section 5 — Demographics & Background
Marital Status:
Single Married Divorced Widowed Other
Current Living Situation:
  • Living Alone
  • With Family
  • Shared Housing
  • Assisted Living
  • Facility-Based Care
  • Other:
Primary Service Provider / Physician / Case Manager
Name:
Phone:
Address:
Cultural / Religious / Personal Preferences (Optional):
Section 6 — Health / Service History (If Applicable)
Primary Condition / Reason for Service:
Secondary Conditions / Background Factors:
Allergies: None Yes (List):
Current Medications / Treatments
Medication Name:
Dosage:
Frequency:
Purpose:
Medication Name:
Dosage:
Frequency:
Purpose:
Medication Name:
Dosage:
Frequency:
Purpose:
Medication Name:
Dosage:
Frequency:
Purpose:
Assistive Devices / Tools Used:
None Cane Walker Wheelchair Equipment Other:
Limitations / Challenges: None Yes (Describe):
Dietary / Lifestyle Restrictions: None Yes:
Mental / Behavioral Considerations:
None Anxiety Depression Cognitive Other:
Safety Concerns (e.g., fall risk, supervision needs):
Section 7 — Needs Assessment / Service Requirements

Services Required (Select all that apply):

  • Personal Care
  • Medical / Clinical Services
  • Therapy / Rehabilitation
  • Supervision / Monitoring
  • Transportation
  • Administrative / Consulting Support
  • Case Management
  • Companionship / Social Support
  • Other:
Level of Service Needed:
Full-Time Part-Time Occasional Project-Based
Preferred Schedule:
Morning Afternoon Evening Overnight Flexible
Section 8 — Communication Preferences
Preferred Method:
Phone Email Text In-Person Portal
Best Time to Contact:
Morning Afternoon Evening
Section 9 — Insurance / Payment Information
Primary Payor / Insurance Provider:
Policy / Reference Number:
Secondary Payor (if applicable):
Policy Number:
Payment Method:
Insurance Private Pay Government Program Other
Section 10 — Legal & Authorization (Optional)
Power of Attorney / Authorized Decision Maker: Yes No
If Yes — Contact Details:
Guardian / Case Worker Information:
Advance Directives / Agreements: Yes No
Section 11 — Goals, Expectations & Preferences
Client Goals:
Service Expectations:
Personal Preferences (staff, schedule, environment, etc.):
Section 12 — Consent & Authorization

I confirm that the information provided is accurate to the best of my knowledge. I authorize the agency to collect, store, and use this information for service delivery, coordination, and compliance purposes.

Client / Representative Name:
Signature:
Date:
For Internal Use Only
Intake Completed By:
Date of Intake:
Service Category Assigned:
Risk Level (if applicable):
Low Medium High
Notes: