ALC Healthcare — General Intake Form

Section 1 — Who is completing this form?

Your Full Name

Your Phone Number

Your Email Address

Best Time to Contact You

Section 2 — Client Information

Client Full Name

Client Date of Birth

Month

Day

Year

Client Phone Number

Client Address

Primary Language

Emergency Contact Name

Emergency Phone Number

Section 3 — Insurance / Coverage (for eligibility review)

Insurance Type

Insurance Plan Name

Member/Policy ID

Section 4 — Services Requested

Primary Reason for Request / Current Needs

Section 5 — Clinical & Safety Snapshot

Any allergies or safety concerns we should know?

Is the home environment safe for staff?

Yes

Not sure / Needs assessment

Section 6 — Schedule & Start Date

When do you need services to start?

Estimated Hours Needed Per Week

Section 7 — Referral / Provider Information (if applicable)

Referring Provider/Facility Name

Provider Phone/Fax

Do you have physician orders/referral documents available?

Yes

Section 8 — Consent & Acknowledgment

Consent Checkbox

I confirm the information provided is accurate to the best of my knowledge. I authorize ALC Healthcare to contact me regarding services, eligibility, and next steps.

Preferred Contact Method