First Name
*
Last Name
*
Date of Birth
*
Address
*
City
*
County
*
Service Location
*
Albany
Americus
Baxley
Columbus
Valdosta
Phone
*
Email
*
Sex
*
M
F
Marital Status
Who Does Client Live With?
*
Monthly Income
*
Income Source
*
Payer Source
*
Private Pay
Medicaid
Long-term Insurance
VA
Medical Information
Diagnosis
*
Dementia/Alzheimer's
Hypertension
Anemia
Arthritis
Bowel or Bladder Problems
Cancer, Leukemia or Tumor
Diabetes
Digestive Disorder
Edema
Effects of Stroke
Tremors
Respiratory Problems (Ex: COPD, Asthma)
Heart Trouble
Emphysema
Vision Impairment
Hearing Impairment
Special Equipment Required (Ex: Wheelchair, Walker or Cane)
Please list any other diagnoses not mentioned above.
Primary Physician
*
Physician's Phone
*
Medicare
*
Yes
No
Medicaid
*
Yes
No
Primary Contact
Relationship to Contact
Contact Phone
Contact Email
Do you need assistance with any of the following?
*
Bathing Assistance
Eating Assistance
Dressing Assistance
Companion/Sitter Services
Transfer
Toileting
Meal Preparation
Light Housekeeping
Errands/Escort
SERVICE TYPE
*
Adult Day Health
Personal Care Home
Structured Family Care Giving
PROPOSED ADULT DAY CENTER SCHEDULE
Monday
Tuesday
Wednesday
Thursday
Friday
Preferred time of contact
*
Morning
Afternoon
Evening (After 5 PM)
How did you hear about us?
*
Website
TV Commercial
Social Media
Radio
Transportation Vehicle
Hospital
Doctor's Office
Case Management
Client/Employee
Care Coach
Call-In/Walk-In
Additional Comments
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