A1 Senior Care Advisors

Referral and Placement Intake Form

    Client Name (required)

    DOB (required)

    Family Member

    Member Name (required)

    Mobile Number(required)

    Email ID (required)

    Recent Medical History (required)

    Known Medications (Brief Info)

    Height/Weight

    Known Medications

    Known Medical Diagnoses

    Keep you own Doctor or use House Doctor?

    Health concerns

    The reasons the client is seeking supportive housing or care services

    Significant known behaviors or symptoms that may cause concern or require special care

    Mental illness, Dementia, Alzheimer's or developmental disability diagnosis, if any

    Assistance needed for Daily Living

    Particular cultural or language access needs and accommodations

    Activity preferences (old and new)

    Sleeping habits of the vulnerable adult, if known

    Bringing own furniture

    Basic information about the financial situation

    Long-term care insurance or financial assistance, including Medicaid

    Current Living Situation

    Geographic location preferences for a potential move in

    Social preferences, food and daily routine

    Client's Detail

    Client's Printed Name

    Client's Signature

    Clients Representative Printed Name

    Relationship

    Clients Representative Signature

    Enter Date

    Authorization: I certify that this request has been made freely, voluntarily and without coercion and that the information given above is accurate and complete to the best of my knowledge. I understand I can refuse to sign this authorization. I understand that I will receive a copy of this form after I sign it. I understand that I can revoke my authorization at any time in writing. Revocation will be effective immediately when received in writing by the Source Releasing the Information and A1 Senior Care Advisors LLC.  I understand that the revocation will not apply to information that has already been released in response to this authorization. Without a revocation request this signed authorization will stay in effect until the needs for disclosure are satisfied. I have read this form, or it has been read and explained to me, and I understand its content.

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