Initial Intake Form Your Name Phone Number Email Address Mailing Address Inquiring For Inquiring ForMotherFatherMother-in-lawFather-in-lawGrandmotherGrandfatherSisterBrotherAuntUncleSpouseOther Their Age Their Age64 or under65+75+85+ Level of Need Level of Need Urgent Looking for the Future Current Living Situation Current Living Situation Own Home Home with daily nurse With friends/family Hospital Rehab Senior Community Other Diagnosis/Health Situation Diagnosis/Health Situation Independent Stroke/TIA Parkinson’s Bone Fracture Dementia/Alzheimer’s Heart Disease/CHF Diabetes Other Please Explain Current Living Situation Please Explain Additional Diagnosis Required Personal Assistance Required Personal Assistance Bathing Dressing Grooming Feeding Medication Management Toileting Incontinence Other Needs/Conditions Needs/Conditions Blindness Speech Impaired Hearing Impaired Diabetic Management Injections Wound Care Oxygen Night Time Assistance Ostomy/Catheter Tracheotomy IV/Tube Feeding Hospice None Other Mobility Mobility Independent Cane/Walker Wheelchair History of Falls Sit to Stand Lift Hoyer Lift Assistance Toileting Transfer Assistance with 1 Transfer Assistance with 2 Please Explain Other Assistance Needs Needs/Condition Other Mental Status Mental Status Sharp Confused Forgetful Social Wandering Agitated Evening Agitation Only Physically Combative Verbally Combative 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+ Other 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 14 + 2 = Submit Form Are you on a mobile device/phone? Tap Here for the Mobile Form