Intake Form

Member/Patient Name:

Date of Intake:

Your Email:

Name

DOB:

Address

Diagnosis: Medical conditions:

Current medication (if applicable)

Allergies:

Assistive Devices?

Legal Competency Status:

Own guardian Pending guardianship Has a legal guardian

Appointed guardian name and phone number:

DDS Eligible

Yes No

If yes, Service Coordinator:

Are you receiving any other services such as; PCA, Home Health Aide, etc.

Are you coming from another AFC agency?

Yes No

If yes, name of agency

Do you attend any program/work?
Contact information:

Schedule:

Physician(S):

NPIa:

Name of PCP:

Phone and Fax:

Address of PCP:

Other Physicians that’s treating this person:

Contacts