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 ___Asian ___Declined Living Situation: ___ Own Home ___ Rental Unit ___ Friend/Relative ___ Homeless ___ Assisted Living ___ Long Term Care Facility ___ Halfway House Currently Living With: ___ Spouse/Partner ___Alone ___Group Setting (non relative) ___ Child ___ Parent-Adult ___ Parent-Child ___ Other (non spouse/partner) Marital Status: ___ Married ___ Divorced ___ Separated ___ Not Married/Single ___ Widowed Employment Status: ___ Full Time ___ Part Time ___ Not Employed ___ 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 _____ MSA ____ Housing

_____ Social Security _____ TANF (AFDC,MFIP) ______ Interest/other ____ Medical Aide

_____ Self Employment _____ SSI ______ No income ____ Veteran’s Benefits

Does the client have a disability? yes no ***if yes, see next page*** Are they certified disabled? in process no SSA SMRT (State Medical Review Team) Assistance: monthly income_____________________ # in household_____ primary language_________________ Veteran? yes no Veteran Relation? self spouse Active Duty Service: Korean War Iraq/Afghanistan Vietnam WWII MN Benefits: yes no PMI #________________________________ Federal Benefits: SSA 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 Carpal Tunnel

Cerebral Palsy Chronic Pain GENERAL

Muscular Dystrophy Obesity Paralysis

Paraplegic Parkinson’s Quadriplegic

Scoliosis Spina Bifida Spinal Cord Injury

Stroke

Specific Disability Information – Chronic Illness

ALS Arthritis Asthma

Cancer COPD Diabetes

End State Renal Disease Environmental Sensitivity Epilepsy

Fibromyalgia GENERAL Heart Disease

High Blood Pressure HIV/AIDS Lupus

Multiple Sclerosis Neuropathy Polio

Specific Disability Information – Cognitive

GENERAL Autism Developmental Disability

Fetal Alcohol Syndrome Learning Disability Memory Loss

Traumatic Brain Injury

Specific Disability Information – Psychiatric

Anxiety Disorder ADD/ADHD Bipolar Disorder

Depression DID Eating Disorder

GENERAL OCD Post Traumatic Stress

Schizophrenia Social Phobia

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