In Take Form – Shifaa

Client Information

Tell us about yourself and the person who will be receiving care.

🔒 This form collects Protected Health Information and is kept confidential.

Intake Date*

Completed By*

Interview With*

Client Family Guardian Other

Referral Source

Client Information

Client's Full Legal Name*

Preferred Name

Date of Birth*

Street Address Where Care Will Be Provided*

Apt / Unit

City*

State*

ZIP Code*

Phone Number*

Email*

Primary Language

Interpreter Needed?

Yes No

Who Lives in the Home With the Client?

Any Pets in the Home?

Yes No

Contacts and Decision-Makers

Who should we coordinate with, and who can make care decisions?

Primary Contact for Care Coordination

Name*

Relationship

Phone*

Legal Representative

Does the Client Have a Legal Guardian, Power of Attorney, or Healthcare Proxy?

Legal Guardian Power of Attorney Healthcare Proxy None

Emergency Contacts

Contact 1 – Name

Relationship

Phone

Contact 2 – Name

Relationship

Phone

Decision-Making

Does the Client Make Their Own Care Decisions, or Does Someone Assist?

Makes Own Decisions Someone Assists Representative Decides

Who Assists, and How?

Disability, Health & Medications

An overview of diagnoses, providers, and medication support.

Disability and Health Overview

Primary Disability or Diagnosis*

Secondary Conditions

Primary Care Physician and Specialists Add each provider the client sees.

Name

Specialty

Phone

Recent Hospitalizations, Surgeries, or Major Health Changes

Allergies Food, medication, environmental

Existing Seizure Plan, Behavior Plan, or Written Care Plan?

Seizure Plan Behavior Plan Written Care Plan None

Medications

Current Medications, Doses, and Schedule Attach list if available

Attach Medication List (optional) PDF, JPG or PNG – max 5 MB

Level of Help Needed

Reminders Assistance Full Administration None

Pharmacy Name

Pharmacy Phone

Daily Living & Household Tasks

For each activity, choose the level of support the client needs.

Activities of Daily Living

Notes

Household and Community Tasks

Mobility, Communication & Cognition

Help us understand equipment, home access, and how the client communicates.

Mobility and Equipment

Equipment Used

Wheelchair Walker Cane Hoyer Lift None Other

Other Equipment

Home Accessibility Stairs, ramps, grab bars, etc.

Any Falls in the Past 6-12 Months?

Yes No

Describe

Communication and Cognition

How Does the Client Communicate?

Verbal Sign Language AAC Device Gestures Other

Hearing or Vision Impairments

Memory, Cognitive, or Intellectual Challenges Affecting Daily Life

Best Way to Explain Things or Give Instructions

Behavioral Support & Nutrition

What helps the client feel safe and comfortable, and any dietary needs.

Behavioral and Emotional Support

Known Triggers, Behaviors, or Situations That Cause Distress

What Calms or Comforts the Client?

Safety Concerns

Wandering Self-Injury Aggression None

Safety Concern Details

Interests, Hobbies, and Favorite Routines

Nutrition

Schedule, Preferences & Payment

When care is needed, caregiver preferences, and how services will be covered.

Schedule and Caregiver Preferences

Payment and Coverage

Payment Source

Medicaid Waiver Private Pay LTC Insurance VA Other

Medicaid/Insurance ID Numbers

Case Manager or Service Coordinator Name

Phone

Authorization or Approved Plan of Care in Place?

Yes In Progress No Not Sure

Goals, Documents & Consent

Almost done – tell us what success looks like and confirm your consent.

Goals

Main Goals for In-Home Care Independence, safety, social connection, etc.

What Does a Successful Day Look Like for the Client?

Anything Else We Should Know to Provide the Best Care?

Consents and Documents Checklist

HIPAA Authorization and Release of Information Service Agreement and Client Rights Consent to Treat / Provide Care Copies of Guardianship or POA Documents Insurance Cards Current Medication List Emergency and Evacuation Plan

Signatures

Client / Representative Signature*

Printed Name*

Date*

Intake Form

Client Information

Contacts and Decision-Makers

Disability, Health & Medications

Daily Living & Household Tasks

Mobility, Communication & Cognition

Behavioral Support & Nutrition

Schedule, Preferences & Payment

Goals, Documents & Consent

Thank You – Your Intake Was Received