Questionnaire for Clients
Intake Questionnaire
E / P

Please note: this is an online agreement and so please do not print this out, please just fill it out online and then click Submit at the end
If you have any questions, call us at 212-614-8057
Thank you!
Home Instead Senior Care
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  • We only cover Manhattan
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  • Please include any special instructions.
  • 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 all activities you would like to see done.
  • Free of charge (equipment and unlimited voice and video and streaming of music, news, video chat with family and Home Instead offices) to all clients with 25 hours or more of service
  • Please let us know if you would like the caregiver to wear her uniform or not. 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 the senior has any specific needs, and where should we instruct the caregiver to be (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.