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