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FH-CL-001 • VERSION 1.0
Client Intake & Initial Service Assessment
Initial needs, goals, schedule, preferences and scope screening.
Digital workflow:
Complete required fields, review carefully, then submit. A submitted record is timestamped and preserved for office review.
1. Record identification
Client name *
Date *
Completed by *
2. Client & responsible party
Legal name
Preferred name
Date of birth
Service address
Primary phone
Email
Responsible party / relationship
Emergency contacts
3. Reason, goals & schedule
Reason for requesting services
Client goals
Requested days and times
Estimated weekly hours
4. Requested support
Companion services
Companionship
Conversation / social engagement
Outings / community activities
Appointment accompaniment
Homemaker services
Meal planning / preparation
Light housekeeping
Laundry / linens
Shopping / errands
Routine household activities
5. Independence, health & safety screen
Routines, preferences and independent abilities
Mobility method / devices / fall concerns
Hands-on care or skilled-care request?
Choose…
No
Yes — administrator review required
Medication reminder requested?
Choose…
No
Yes
Home access, pets, smoking and hazards
Transportation, errands or funds requested
6. Proposed services & review
Proposed services
Proposed schedule
Rate / fee arrangement
Accepted for service?
Choose…
Pending
Yes
No
Conditions / limitations
7. Certification / acknowledgment
Electronic signature / typed name *
Signature date *
Notes
Submit secure office copy
Print downtime copy