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.

Looking For Free Advice ?

mic1.425.324.5592

to speak with an Advisor

maila1careadvisors@gmail.com

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Looking For Free Advice ?

senior assisted living facilities and adult family homes near me1.425.324.5592

to speak with an Advisor

senior assisted living and senior care adult family home livinga1careadvisors@gmail.com

DROP US AN EMAIL AT ANYTIME, We WILL REPLY TO YOU IN THE NEXT FEW HOURS