Home Health Care Services Intake Form

Home Health Care Services Form

Section 1: Client Informaiton


Section 2: Emergency Contact


Section 3: Guardian / Responsible Party (if applicable)


Section 4: Primary Care Provider


Section 5: Insurance Information


Section 6: Health Information


Section 7: Services Requested


Section 8: Functional & Daily Living Needs


Section 9: Cultural & Personal Preferences


Section 10: Consent & Signatures


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WHO CAN CALL?


This crisis helpline is for anyone who is experiencing emotional distress, personal crisis, or urgent mental health support needs.

You can call if you are:

• Feeling overwhelmed, anxious, or unable to cope
• Experiencing emotional pain, panic, or severe stress
• Facing a personal or family crisis
• Feeling hopeless, alone, or in need of immediate support
• Worried about your safety or the safety of someone else
• Supporting a loved one who is in crisis and need guidance

Note:
This hotline is strictly for crisis support and emotional assistance.
It is not for food assistance, shelter requests, or general service inquiries.