Initial Intake Form Name Phone Number Email Address Mailing Address Inquiring For Inquiring ForMotherFatherMother-in-lawFather-in-lawGrandmotherGrandfatherSisterBrotherAuntUncleSpouseOther Their Age Their Age64 or under65+75+85+ Current Living Situation Current Living Situation Own Home Home with daily nurse With friends/family Hospital Rehab Senior Community Level of Need Level of Need Urgent Looking for the Future Diagnosis/Health Situation Diagnosis/Health Situation Independent Stroke/TIA Parkinson’s Bone Fracture Dementia/Alzheimer’s Heart Disease/CHF Diabetes Other Required Personal Assistance Required Personal Assistance Bathing Dressing Grooming Feeding Medication Management Heart Disease/CHF Toileting Incontinence Other Please Explain Additional Diagnosis Please Explain Other Assistance Needs Mental Status Mental Status Sharp Social Confused Forgetful Wandering Agitated Evening Agitation Only Physically Combative Verbally Combative Ambulation Ambulation Ambulatory History of Falls Cane/Walker Wheelchair Sit to Stand Lift Hoyer Lift Toileting Transfer Assistance with 1 Transfer Assistance with 2 Needs/Conditions Needs/Conditions Blindness Speech Impaired Wound Care Tracheotomy Hearing Impaired Diabetic Management Injections Oxygen Ostomy/Catheter IV/Tube Feeding Night Time Assistance Hospice Type of Community Type of Community Independent Living Assisted Living Memory Care AFC Home Respite Care Continuum of Care Skilled Nursing Low Income Type of Unit Type of Unit Studio Semi-Private Private Bath 1 Bedroom 2 Bedroom 3 Bedroom Amenities Amenities Meals Laundry Housekeeping Transportation Outings Activities Utilities Pets Smoking Insurance Benefits Insurance Benefits Medicare Medicaid Medicaid Waiver Long Term Care Insurance Veteran Spouse of a Veteran Reverse Mortgage Gross Income (per person) Gross Income (per person) Less than $1,000 per month $1,000 to $1,500 per month $1,500 to $2,200 per month $2,200 to $3,500 per month $3,500+ Savings/Annuities Savings/Annuities None Less than $10,000 $10,000 - $50,000 $50,000 - $100,000 $100,000+ Geographical Preference Geographical Preference Downtown TC East TC West TC Old Mission Leelanau County Kalkaska County Antrim County Wexford County Other Please Explain Other Geographical Preference 8 + 6 = Submit Form