SeniorCare Homecare Intake Form

SeniorCare Homecare Intake Form

Updated: 4/1/2022
When anticipating discharge from a hospital/rehabilitation facility,
PLEASE DO NOT SEND PRIOR TO THE DISCHARGE DATE.

For those residing in a community/home setting, complete and submit this form, and an Information & Referral specialists will reach out to you. If you have technical difficulties with this form, please reach out to SeniorCare via phone at 978-281-1750.
- Name of person completing this form*
  
  First NameLast Name
- Organization & TItle
- Address*
  
  Street Address
  
  Street Address Line 2 (if needed)
  
  CityState
  
  Zip Code
- Email*
  example@example.com
- Phone Number*
  Format: (000) 000-0000.
- What is the relationship between the person completing this form and the consumer?*
- Name of consumer*
  
  First NameLast Name
- Address*
  
  Street Address
  
  Street Address Line 2 (if needed)
  
  CityState
  
  Zip Code
- CONSUMER'S Phone Number*
  It is VERY IMPORTANT that the consumer's actual phone number be entered here. You can indicate that calls should not be made to this number later in the form.Format: (000) 000-0000.
- Date of Birth*
  
  MonthDayYear
  Date
- Alert & Oriented*
  
  YesNo
- Lives Alone*
  
  YesNo
- Marital Status*
  
  SingleMarriedWidowedDivorced
- Veteran Status*
- Housing*
  
  Owns homeRents home
- Housing Type*
  
  HouseCondoApartment
- Housing Authority
- Smokes*
  
  YesNoUnknown
- Pets*
  
  YesNoUnknown
- Name*
  
  First NameLast Name
- Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Relationship to Consumer*
- Medicare*
  
  YesNo
- MassHealth*
  
  YesNo
- If answered "Yes" to MassHealth, please enter MassHealth Number*
  If entered "No" to MassHealth, enter N/A
- PCP Name*
  
  First NameLast Name
- PCP Phone*
  Please enter a valid phone number.Format: (000) 000-0000.
- Major Medical Conditions
- Hospital Admission in Last 90 Days?*
  
  YesNoUnknown
- If answered "Yes" to hospital admission, please indicate which hospital and dates of stay-- Both ADMIT and DISCHARGE dates are very important*
  If answered "No" to hospital admission, enter N/A
- If answered "Yes" to hospital admission, please indicate reason for admission*
  If answered "No" to hospital admission, enter N/A
- If answer "Yes" to hospital admission, did the consumer stay at a rehab facility following the hospital stay?*
  
  YesNoUnknown
- If answered "Yes" to rehab admission, please indicate which rehab facility and dates of stay*
  If answered "No" to rehab, enter N/A
- Rehab discharge date*
  
  MonthDayYear
  Date
- Was VNA involved?*
  
  YesNoUnknown
- If answered "Yes" to VNA involvement, please indicate which VNA*
  If answered "No" to VNA, enter N/A
- Is the Consumer aware of this referral?*
  
  YesNoUnknown
- Contact Consumer to complete referral?*
  
  YesNo
- If Consumer is not aware of this referral, why?*
- If consumer is not to be contacted, please explain why
- If Consumer is not to be contacted to complete referral, who should be contacted?*
  
  First NameLast Name
- Phone number for contact to complete referral*
  Please enter a valid phone number.Format: (000) 000-0000.
- Relationship to the Consumer of contact
- Which of the following services are being requested?*
  
  HomemakerHome delivered mealsPersonal careMeal PreparationMoney ManagementLaundryShoppingCompanionOther
- Family Caregiver Support Group?*
  
  YesNo
- Options Counseling?*
  
  YesNo
- Please include any additional comments and/or information, as appropriate
- Please do not send this form prior to the discharge date
- Please do not send medical records. Send this form ONLY
  
  Thank You
- Please verify that you are human*
- Should be Empty:

SeniorCare Homecare Intake Form

Please do not send this form prior to the discharge date

Please do not send medical records. Send this form ONLY