Client Intake Form Client Intake Form Full Name *Date of Birth *Gender *SelectMaleFemaleStreet AddressCityState/ProvinceZIP / Postal CodePhone NumberEmail Address *Preferred Language *Please answer the following questions honestly and to the best of your knowledge.A. General HealthHow would you rate your overall health? *ExcellentGoodFairPoorDo you currently have or have you ever had any of the following conditions? (Check all that apply): *DiabetesHypertension (High Blood Pressure)Heart DiseaseStrokeAsthmaCOPD or other lung conditionsEpilepsy or seizuresKidney DiseaseLiver DiseaseThyroid ProblemsCancerMental Health Disorders (e.g. Depression, Anxiety)Arthritis or Joint ProblemsChronic PainOtherPlease specify type *Please specify *Do you take any medications regularly? *YesNoIf yes, please list them: *Do you have any known allergies? *YesNoIf yes, please specify (medications, food, environmental, etc.): *Do you have any physical disabilities or limitations? *YesNoIf yes, please describe: *Start Date *Frequency *DailyWeeklyAs NeededPreferred Days/Times *HoursMinutesAM/PMAMPMNumber of Hours per Visit *Preferred Caregiver Gender (if any) *MaleFemaleNo PreferencePlease list any personal preferences, routines, cultural considerations, or specific instructions: *Hourly Rate (per hour)Total Estimated Weekly HoursPayment Method *CashBank TransferChequeOtherInvoicing *WeeklyBi-weeklyMonthlyLate Payment PolicyCancellation PolicyPlease read and acknowledge:I understand that the services provided are non-medical in nature and do not include any clinical, nursing, or medical interventions.I agree to treat all caregivers with respect and ensure a safe workingenvironment.I acknowledge that schedules and caregiver assignments are based onavailability and may change due to unforeseen circumstances.I understand that any concerns or complaints should be reported directly to the agency/provider for resolution.I agree to provide 24 hours’ notice for cancellations whenever possible.I acknowledge that I am responsible for payment of all agreed-upon services rendered.I give consent for the agency/provider to collect and use the informationprovided in this form for the sole purpose of delivering care services.I have read, understood, and agree to the terms outlined above.Client/Representative Name *Signature *Date *Agency Representative NameSignature *Date *Referrals *SelectYesNoSubmit
