Homemaking Client Intake Form

Date: ____________________________

Contact Person: ______________________________________
Contact address: _________________________________________________________ Contact Phone #: _____________________________
Client Name: _________________________________________
(individual needing services)

Address: __________________________________________________

City/State/Zip: ________________________________________

Birthdate: _________________________ Phone Number: _______________________________

Email: _____________________________________

Social Security #: ____________________________
Ethnicity: ___ White ___ American Indian

___Hispanic

___African American

Living Situation: ___ Own Home ___ Rental Unit ___ Friend/Relative
___ Long Term Care Facility ___ Halfway House

___Asian

___ Homeless

___ Assisted Living

Currently Living With: ___ Spouse/Partner ___Alone ___Group Setting (non relative)
___ Parent-Child ___ Other (non spouse/partner)
Marital Status: ___ Married

___ Divorced

Employment Status: ___ Full Time

___ Separated

___ Part Time

___ Not Married/Single

___ Not Employed

___Declined

___ Child

___ Parent-Adult

___ Widowed

___ Self Employed

Check all sources of income that are received by members of your household:
_____ Salary or wages
____ General Assistance
______ Retirement, Pension

____ Food Stamps

_____ Alimony/Child Supp. ____ Unemploy. Comp

____ Housing

_____ Social Security

_____ TANF (AFDC,MFIP) ______ Interest/other

_____ Self Employment _____ SSI
Does the client have a disability?
yes
Are they certified disabled? in process
Assistance:

_____ MSA

______ No income
no
no

monthly income_____________________

Veteran?
yes
Veteran Relation?

no
self

Active Duty Service:

Korean War

MN Benefits: yes
Federal Benefits:

no
SSA

____ Medical Aide
____ Veteran’s Benefits

***if yes, see next page***
SSA
SMRT (State Medical Review Team)
# in household_____

primary language_________________

spouse
Iraq/Afghanistan

Vietnam

WWII

PMI #________________________________
SSI
SSDI SSI & SSDI

Social Security Number # __________________________________
Medicare:
yes
no
Medicare # _____________________________________
What is the client’s need or concern? (Please explain)
_________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
How often:_______________________________________________ Confirm Income (Tax Return)_____________________________________________
2/2011

Specific Disability Information – Physical  Amputation  Back Problems  Cerebral Palsy  Chronic Pain Muscular Dystrophy  Obesity  Paraplegic  Parkinson’s  Scoliosis  Spina Bifida  Stroke Specific Disability Information – Chronic Illness  ALS  Arthritis  Cancer  COPD  End State Renal Disease  Environmental Sensitivity  Fibromyalgia  GENERAL  High Blood Pressure  HIV/AIDS  Multiple Sclerosis  Neuropathy  Carpal Tunnel  GENERAL  Paralysis  Quadriplegic  Spinal Cord Injury  Asthma  Diabetes  Epilepsy  Heart Disease  Lupus  Polio Specific Disability Information – Cognitive  GENERAL  Autism  Fetal Alcohol Syndrome  Learning Disability  Traumatic Brain Injury  Developmental Disability  Memory Loss Specific Disability Information – Psychiatric  Anxiety Disorder  ADD/ADHD  Depression  DID  GENERAL  OCD  Schizophrenia  Social Phobia  Bipolar Disorder  Eating Disorder  Post Traumatic Stress Specific Disability Information – Chemical Dependency  Alcoholism  Drug Addiction  GENERAL Specific Disability Information – Hearing  Deaf  GENERAL  Hearing Loss Specific Disability Information – Visual  Blind  GENERAL  Vision Loss Specific Disability Information – Speech  GENERAL  Non-Verbal  Speech Impairment Specific Disability Information – Temporary GENERAL  Short-term Disability .