Intake Paperwork Preview — Common Ground

About the person attending

Full name *

Address *

City

State

ZIP code

Phone

Parish or county

Gender

Marital status

Date of birth *

Right- or left-handed

Physician name *

Physician phone *

If you chose American Indian/Alaska Native, Asian, Pacific Islander, or Other, please specify

Fluent languages

EnglishSpanishFrenchOther

Other languages

If other, please explain

Approximate year of diagnosis

Responsible party

Complete this if someone other than the person attending is responsible for payment.

Full name *

Relationship to the person attending *

Address, if different from the person attending

City

State

ZIP code

Home phone

Work phone

Cell / mobile number *

I acknowledge responsibility for payment of all program fees. If the account becomes delinquent, I am liable for collection and legal fees. *

About the caregiver

The person who provides day-to-day care at home.

Caregiver's name *

Caregiver lives at the same address as the person attending

Address *

City *

State

ZIP code

Phone *

Parish or county

Email *

Date of birth

Caregiver's relationship to the person attending *

Program enrollment and daily support

How much help does the person need with each activity?

Who referred you to the program?

Eating

Getting in and out of bed

Getting around inside

Dressing

Bathing

Using the toilet

Doing heavy housework

Doing light housework

Doing laundry

Cooking / preparing meals

Buying or getting food and clothes

Getting around outside

Going places outside of walking distance

Managing money

Taking medicine

Using the telephone

Hours per week the caregiver helps with eating, bathing, dressing, or toileting

Hours per week spent on meal preparation, laundry, or light housework

Hours per week providing transportation to appointments or shopping

Hours per week on legal matters, banking, or paperwork

What are the top 3 goals for time in the program?

For example: making friends, gaining community, building new skills, staying active, etc.

What other information would be helpful to you?

Behavioral information

Check yes or no, and add a short explanation wherever it helps.

Is the person manageable for you at home right now?

Anything you'd like to add

At home, problems with: sleep patterns

Sleep patterns — details

At home, problems with: eating habits

Eating habits — details

At home, problems with: mobility

Mobility — details

At home, problems with: wandering

Wandering — details

At home, problems with: incontinence

Incontinence — details

At home, problems with: level of anxiety

Level of anxiety — details

At home, problems with: level of cooperation

Level of cooperation — details

At home, problems with: level of contentment

Level of contentment — details

At home, problems with: expressions of happiness

Expressions of happiness — details

At home, problems with: anything else (for example, a change in medication)

Anything else (for example, a change in medication) — details

Health and demographic information

Medications currently taken

List all medications the person currently takes, including name and dose.

Medications taken during program hours

Name, dose, and time. Leave blank if none.

Any difficulty with food, eating, or swallowing?

If yes, please describe

Does the person follow a special diet?

If yes, please describe

Allergies

List any allergies (food, environmental, drug, or anything else).

Drug allergies

Sign and send

When filling this out for real, families type their full name as a signature, then submit. Our staff review it and approve it before plans and booking open up.

Your full name

A look at the intake paperwork

About the person attending

Responsible party

About the caregiver

Program enrollment and daily support

Behavioral information

Health and demographic information

Sign and send