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

Looking For Free Advice ?

mic1.425.324.5592

to speak with an Advisor

maila1careadvisors@gmail.com

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

Looking For Free Advice ?

mic1.425.324.5592

to speak with an Advisor

maila1careadvisors@gmail.com

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