Client Intake Form

Client Information

Client Full Name *

Date of Birth *

Primary Address (Care Location) *

Primary Phone *

Email *

Responsible Party / Emergency Contact

Name *

Relationship to Client *

Phone Number *

Email *

Power of Attorney / Healthcare Proxy

Care Request Overview

What prompted the need for care? *

Desired Start Date *

Schedule & Coverage Needs

Preferred Schedule *

Weekdays Weekends Evenings Overnight 24-Hour / Live-In

Estimated Hours Per Week *

Mobility & Safety

Mobility Level *

Independent Standby Assist Hands-on Assist Two-Person Assist

History of Falls (last 6 months) *

No Yes

Assistive Devices Used

Cognition & Behavior

Memory Concerns *

None Mild Diagnosed Dementia

Behaviors Observed

Wandering Sundowning Agitation Nighttime Wakefulness

Personal Care Needs (Non-Medical)

Bathing Dressing Toileting Incontinence Care Grooming

Daily Support & Companionship

Meal Prep Medication Reminders Light Housekeeping Laundry Companionship Transportation

Dietary & Nutritional Information

Food Allergies (if any)

Dietary Preferences

Regular Low Sodium Diabetic-Friendly Vegetarian

Foods Client Enjoys

Foods to Avoid

Swallowing Concerns

No Yes

Routines, Habits & Personal Preferences

Typical Wake-Up Time

Typical Bedtime

Daily Routine Notes (TV, reading, prayer, hobbies, etc.)

Personal Preferences Important to Client

Communication & Personality

Preferred Name / Nickname

Primary Language

Communication Style

Talkative Quiet Needs prompting

Things That Calm or Comfort the Client

Triggers or Stressors to Avoid

Home Environment & Pets

Pets in Home

No Yes

Smoking in Home

No Yes

Stairs in Home

No Yes

Special Household Instructions

Additional Notes

Additional Notes / Caregiver Tips

I understand that Golden Path Companion Care provides non-medical companion care services and that care plans and pricing may be adjusted as care needs change.