Intake Form | EverCareAdvisors

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EverCareAdvisors

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FAQ
Intake Form

Your Information

First name*

Last name*

Email*

Phone*

Multi-line address

Country/Region

Address

City

Zip / Postal code

Individual needing Care

Persons name*

Birthday

Month

Day

Year

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Care needs and information

Summary of the situation and required care.

Estimated move Time*

Monthly Budget *

Do they have long-term care (LTC) insurance?*

Owns Home (Estimated Value?)

Are they Veteran? (VA Benifints)

Private Pay Time Period

Private pay Notes

Medicaid information*

Not eligible for Medicaid

Likely has less than 1 month of funds at $9K or less

Likely has under 6 months of funds (less than $60K)

Likely has more than 6 months but less than 1 year of funds (around $80K)

Personality/Behavior

Calm/Pleasant

Socially Engaged

Enjoys Activities/Hobbies

Frequent Yelling

Aggressive Behavior

Delusional Thoughts

Experiences Hallucinations

Resists Care

Verbally Aggressive

Attempts to Leave (Exit-Seeking)

Prone to Wandering

Repetitive/Compulsive Behaviors

Personality/Behavior Notes

What are/were their hobbies and interests?

Height*

Weight *

Condition

Alert / No Dementia

Some Memory Loss

Dementia

Alzheimer's

Other

Condition Notes

Ability to Transfer

Independent

Stand-by

1 Person Transfer

2 Person Transfer

Hoyer or Sit-Stand Lift

Ability to Transfer Notes

Ambulation

Independent

Cane

Walker

Wheelchair

Power Wheelchair

Electric Scooter

Bedridden

Fall History

Ambulation Notes

Incontinence

Bladder Incontinence

Bowel Incontinence

Colostomy

Foley catheter

Incontinence Notes

Needs Medication Administration (oral)

Special Dietary Needs

Regular

Mechanical Soft Diet

Pureed Diet

Vegetarian

Gluten Free

Dairy Free

Special Dietary Needs Notes

Primary diagnosis (main health condition)

Additional health notes (eye conditions/history)

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Intake Form

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