CLIENT SERVICE APPLICATION & INTAKE FORM

PERSONAL INFORMATION

First Name

Last Name

Date of birth

Phone *

Email *

Last 4 SSN

Gender

Primary Language

Address

Street Address

City

State

Country

Postal Code

RESPONSIBLE PARTY :

Responsible Party Name

Relationship to Client

Responsible Party Phone

Responsible Party Email

EMERGENCY CONTACT

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone

PAYMENT TYPE

Payment Method

Private Pay

Long-Term Care Insurance

Medicaid

VA Benefits

Insurance Company

Policy Number

SERVICES REQUESTED

Preferred Schedule (Days & Hours)

Requested Start Date

HEALTH CONDITIONS

Allergies

Current Medications

FUNCTIONAL STATUS

Assistance with Bathing?

Assistance with Dressing?

Assistance with Toileting?

Assistance with Walking?

Assistance with Eating

HOME ENVIRONMENT

Lives Alone?

Pets in Home?

Type of Pets

Smoking in Home?

Safety Concerns

CONSENT

I certify that all information provided is accurate and I authorize Confort Care Senior Care to contact me regarding services.

Comfort Care Senior Care is an Equal Opportunity Employer.

All employment is contingent upon background verification and compliance with Alabama state regulations.