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Sunset Elite Homecare

Client Intake Form

Thank you for your interest in Sunset Elite Homecare LLC. Please complete this Client Intake Form so we can better understand your care needs and determine how we may assist you or your loved one.

Date of Birth
Month
Day
Year
Multi-line address

Contact Person/Responsible Party

Relationship

Services Needed

Does the client have any medical conditions we should be aware of?

Please select all that apply:

Care Schedule Needed

Perferred Start Date

Date
Month
Day
Year

Days Needed:

Preferred Hours of the Day:

Time frame:

Estimated Amount of hours per week:

Client Care Needs

Please briefly describe the type of assistance needed:



Does the client need help with any of the following:

Health & Safety Information

Does the client have any medical conditions we need to be aware of?

Do the client use any equipment?

Does the client have allergies:

Is the client a fall-risk:

Acknowledgement

Name of person completing the form:

Relationship to Client:


Electronic Signature:

Date:


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