Client Intake - Aixa Care Services

Client Information

Client full name(Required)

Age(Required)

Please enter a number from 0 to 120.

Date of birth(Required)

Home address(Required)

City(Required)

Primary language(Required)

Does the client live alone?(Required)

Yes

No

Who else is in the home?

Family / Responsible Party

Primary contact full name(Required)

Relationship to client(Required)

Phone number(Required)

Email address(Required)

Emergency contact name(Required)

Emergency contact phone number(Required)

Home / Safety

Is parking available?(Required)

Yes

No

Are there pets in the home?(Required)

Yes

No

Is there any smoking in the home?(Required)

Yes

No

Any safety concerns in the home?

Payment

Preferred payment method(Required)

Zelle

How often will payment be made?(Required)

After each shift

Daily

Weekly

Has the family reviewed and agreed to caregiver rates?(Required)

Yes

No

Additional Notes

Is there anything else you would like me to know about the client or care needs?

Agreement

I confirm that the information provided is accurate to the best of my knowledge.(Required)

Yes

Name of person completing this form(Required)

Signature(Required)

Date(Required)

Client Information

Family / Responsible Party

Patient Condition

Care Needs

Schedule

Home / Safety

Payment

Additional Notes

Agreement