Elder Care Consultation Intake Form

Date (MM/DD/YY):

Please provide the following information and return this form to me prior to our appointment day.

Information about you, the caregiver:

Name:
Address:

Phone number: Home Work Cell

I'd prefer consultation by: Phone In person

Best time for consultation (please check possible times):
Monday Tuesday Wednesday Thursday Friday.
Mornings Afternoons Evenings

Your relationship to the Elder(s):
Adult child Sibling or other relative Friend
Other:

Information about the Elder(s):

First name(s):
Date(s) of birth:
Age(s):
Current location (city/state):


Living situation:
Own home
Lives with family
Skilled nursing facility
Assisted living facility
Board and care
Senior living
Other:

Medical problems (diagnoses) including hospitalizations in last 6 months:


Describe any losses or life changes your parent has had in the past 2 years:


Is monthly income less than $850 for an individual or $1700 for a couple? Yes No
If yes, approximate income amount:

Approximate value of assets (not including home):
Less than $3000
$3000 to $10,000
$10,000 to $100,000
Greater than $100,000

Please check which documents exist:
Advance Directive for Health Care (or Living Will or Durable Power of Attorney for Health Care)
Durable Power of Attorney for Finances
Do Not Resuscitate Order
Will or Trust Document

List any agencies or professionals that are currently providing services:


Describe any beliefs or personality traits that make it difficult for the elder to make changes or accept help:

Additional information

Describe your role as a caregiver including the impact that caregiving is having on your life:


Briefly describe the reason for this consultation and any specific issues or questions you would like to address:


Please note any other important information:


I understand that any recommendations made by Margo Frank LCSW are based solely on the above information and our phone conversation. I agree to hold her harmless regarding the consequences of any decision I make regarding the care of named older adult(s). I have read the attached rate sheet and am aware of all fees. I agree to pay all fees within 10 days of the phone consultation. I understand there is a $25 non refundable deposit due prior to the phone consultation.