Questionnaire for Clients
Intake Questionnaire

E / P

Please note: this is an online questionnaire and so please do not print this out, please just fill it out online (as much as you can) and then click Submit at the end
If you have any questions, call us at 212-614-8057
Thank you!
Home Instead
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  • We only cover Manhattan
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  • Please describe (i) type of pet (ii) size (iii) is there any expectation of us providing any care for this pet (as this may require an additional fee).
  • If currently hospitalized, please provide reason for admission and location.
  • Please specify if there is a next of kin, family member or legal guardian involved with decision making.
  • 1) If the client needs help, please provide details.
    2) What equipment (cane, wheelchair) is used?
    3) Is the client a fall risk?
  • Please include all info that would be helpful
  • Please include any special instructions
  • Please include any special instructions
  • Please include any special instructions
  • Please include all activities you would like to see done.
  • Please let us know if you would like the caregiver to wear a uniform or not (we encourage this for reasons of hygiene, safety and professionalism). If you have any other requests or instructions regarding the caregiver, please include them here.
  • If you are requesting overnight services, please let us know if
    1) the senior has any specific needs at night to be aware of (example - Senior is a wandering risk etc),
    2) where should we instruct the caregiver to be during the shift (bedside, living room, etc).
  • Please include any special instructions, behavioral issues, etc.
  • So we can refer to medicare providers in the area of Physicians, Physical Therapy, Podiatrists and even equipment.
  • Please include any special instructions.
  • Please include any special instructions.
  • Please note that the information provided above will be reviewed with you during our Nurse's initial visit or Care Consult.