Section 1: Referral / Inquiry

Client Name: _______________________________________________

Date of Birth: ___________________   Gender: _______________

Address: __________________________________________________

Phone: ___________________   Email: ______________________

Emergency Contact (Name/Phone): ___________________________

Preferred Services: ________________________________________

Basic Health / Functional Status: ___________________________

Eligibility (service area/nature of care): _____________________

Section 2: Initial Assessment Visit

Assessment conducted by (Name/Title): ________________________

Date of Assessment: ___________________

Method: ☐ In-Person ☐ Tele-Assessment
Evaluation:

ADLs (Bathing, Grooming, Toileting, Dressing, Mobility): ________

IADLs (Meal Prep, Housekeeping, Errands, Laundry, Finances): ____

Cognitive Status: ____________________________________________

Social Support: ______________________________________________

Home Environment: __________________________________________

Identified Risks: ☐ Falls ☐ Medication Oversight ☐ Wandering ☐ Pets ☐ Smoke Detectors ☐ Emergency Plan ☐ Other: ____________

Section 3: Service Plan Development

List of Needed Services (tasks, frequency, durations): _____________

Client Goals / Outcomes: _____________________________________

Schedule / Time Windows: ___________________________________

Backup / Contingency Plan: __________________________________

Client Responsibilities: _______________________________________

Section 4: Care Coordination & Communication

Permission to Share Service Plan with Providers: ☐ Yes ☐ No

Providers Involved: __________________________________________

Notes / Observations Shared: _________________________________

Updates / Changes to Service Plan: ____________________________

Reviewed on: _____________  by: _________________

Acknowledgment 

I have received the Intake, Assessment, and Service Plan in my native language, with the assistance of an interpreter/translator provided by the agency.

Client / Representative Signature: _____________________________ Date: _____________

Interpreter / Translator Signature: _____________________________ Date: _____________
Agency Representative Signature: _____________________________ Date: _____________

Note: This form will be completed and assessed by the Agency’s Care Coordinator only. For inquiries, please refer to the Inquire tab.