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

____ Veterans 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 clients 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
Parkinsons
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