Client Intake Form

Tell us about the person who needs care. All information is securely stored and accessed only by our care team. Prefer paper? Download the PDF.

Client Information

First name *Last name *

Date of birthCity

Street addressPostal code

Contact

Primary phone *Email *

Preferred contact methodBest time to contact

Emergency Contact

NameRelationship

Phone

Services Requested

Personal CareCompanionshipDementia SupportRespite CareMental Health SupportLive-In CareMedication RemindersMeal PreparationTransportation

Care frequencyPreferred start date

Health & Living Situation

Living situationMobility

Cognitive statusMedical conditions (diagnoses, recent surgeries)Current medications (name, dose, frequency)

AllergiesDietary needs / preferences

Funding

How will care be paid for?

Person Completing This Form (if not the client)

Your nameRelationship to client

Your phone

Anything Else We Should Know

Notes

I consent to Ubuntu Haven Living storing the information above and contacting me about care services. I understand my information is kept confidential and is only accessed by authorized staff. *

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