Home Care Client Intake Form Template (NON MEDICAL)

This quick intake form enables you to gather important details about a potential client and help to determine whether the services you offer are suited to the individual's needs, interests and concerns.

2 PAGES- 8.5x11"

⭐ Designed for Professional Use:

✔ Home care agency administrators
✔ Intake coordinators & office managers
✔ Case managers & care coordinators
✔ Senior care consultants
✔ Non-medical home care providers

 ⭐ What This Template Captures:

✔ Client demographic information
✔ Authorized contact details
✔ Health and functional status
✔ Communication ability & support system
✔ Requested services & care timeline
✔ Residence type and daily living needs
✔ Eligibility for agency services
✔ Follow-up actions and tracking
✔ Assessment scheduling & outcomes

Each section is clearly structured to streamline intake and reduce documentation gaps.

⭐ Key Advantages:

✔ Establishes a standardized intake process
✔ Ensures accurate data collection from the first call
✔ Improves coordination between teams
✔ Enhances professionalism and clarity
✔ Supports compliance, audits, and documentation standards
✔ Helps staff quickly identify care needs and suitability

⭐ File Features:

✔ Editable MS Word document (add branding & modify fields)
✔ Fillable PDF for electronic form completion
✔ Print-friendly layout
✔ Professional formatting suitable for client records

⭐ Why Agencies Choose Wise Caregiving

Developed by Danielle, a home care business owner with professional experience in agency operations, client intake, and compliance documentation.
Every template is thoughtfully designed to meet real-world workflow needs — not AI-generated or mass-produced.

⭐ More Essential Agency Forms:

Client Assessment Forms • Intake Packets • Employee Handbook • Daily Logs • Incident Reports • Emergency Procedures

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⭐ WISECAREGIVING COPYRIGHT NOTICE

Original copyrighted template. Redistribution or resale is prohibited.
Unauthorized use is monitored and enforced.