Hands of Choice Healthcare Client Intake Survey

Thank you for choosing Hands of Choice Healthcare.

Kindly complete this intake form so we can provide you with the best possible care.

Your information is secure and confidential.

Personal Information

First Name *

Last Name *

Email *

Phone *

Region 3 Areas of Service

Region 4 Areas of Service

Gender

Emergency Contact

Emergency Contact Name

Relationship

Phone Number

Contact Address

Medical Information

Primary Diagnosis

Secondary Conditions

Current Medications

Allergies

Physician Name

Physician Phone

In-Home Care Services

Care Needs

Hours of Care Needed

Mobility Level

Requires Transportation

Yes

Needs Meal Preparation

Yes

Needs Medication Reminder

Yes

Insurance & Medicaid

Insurance Provider

Policy Number

Medicaid Status

Medicaid ID Number

Document Upload

Upload Photo ID

Upload Insurance Card

Upload Medicaid Documents

Upload Care Plan

Care Preferences

Preferred Care Schedule

Language Preference

Special Instructions

Consent & Signature

Privacy & Information Use I authorize Hands of Choice Healthcare to collect, use, and securely store my personal and health information for the purpose of providing care services and coordinating support as needed.

Yes

Client Signature

Clear