HOME
ABOUT US
- WORK WITH US
SENIOR CARE SERVICES
- DAILY LIVING
- SPECIALIZED HEALTH CARE
CARE & SAFETY MONITORING
SERVICE AREA
CONTACT US

HOME
ABOUT US
- WORK WITH US
SENIOR CARE SERVICES
- DAILY LIVING
- SPECIALIZED HEALTH CARE
CARE & SAFETY MONITORING
SERVICE AREA
CONTACT US

Get Started With Personalized Senior Care

The best way to apply for services with Legacy Life Home Care Services in Montclair, NJ, is by filling out our easy intake form. If you have any questions, call us at 973-775-9222. Get started today!

INTAKE INTERVIEW

Date

Time

Patient Record

NEW

REOPENED

Name of Person calling

Relation to Client

Phone

Agency calling

Address

How did the caller find out about us?

CLIENT

NAME

PHONE

ADDRESS

Street

Apt.#

City

State

Zip

DOB

AGE

GENDER

M

F

DIAGNOSIS

Primary

Past Medical History

Physician

Name

Phone

Street

City

State

Zip

EMERGENCY CONTACT

Name

Relationship to Client

Phone

Home

Cell

Work

Address

Street

Apt.#

City

State

Zip

SERVICE REQUESTED

Personal Care

Homemaking

Companion

Live-in

SETTING

Home/Residence of Client

Apartment

Detached home

Attached home

Facility

Other

Living Arrangements

Alone

With Spouse

With adult child

With children

Name

Number of people in home

FUNCTIONAL STATUS/LIMITATIONS

SPECIAL INSTRUCTIONS/SKILLS REQUIRED

SPECIAL EQUIPMENT TO OPERATE

OTHER SERVICES IN THE HOME

Other Information (Pets, language, customs, etc.)

MEDICATIONS

Asked but not known at this time

Medication

Dose

Medication

Dose

SERVICE REQUESTED

Certified Home Health Aide(CHHA)

Companion (No personal Care)

Live-in

Registered Nurse

Other

HOURS/DAYS TO WORK

Hours

Days

Mon

Tue

Wed

Thu

Fri

Sat

Sun

Hours

Days

Mon

Tue

Wed

Thu

Fri

Sat

Sun

Hours

Days

Mon

Tue

Wed

Thu

Fri

Sat

Sun

COMMENTS

START OF CARE DATE

Staff Name (Print)

Signature

Date

HOURS/DAYS TO WORK

Hours

Days

Mon

Tue

Wed

Thu

Fri

Sat

Sun

Hours

Days

Mon

Tue

Wed

Thu

Fri

Sat

Sun

Hours

Days

Mon

Tue

Wed

Thu

Fri

Sat

Sun

Hours

Days

Mon

Tue

Wed

Thu

Fri

Sat

Sun

MEDICATIONS

Medication

Dose

Medication

Dose

CHHA/COMPANION/LIVE-IN DUTIES (See Plan of care for details)

Personal care

Grooming

Ambulation

Dressing

Transferring

Exercise

Shopping

Meal planning and preparation

Light Housekeeping

Laundry

Change bed linen

Companionship

Transport

Other

Special policies or certifications

NURSE DUTIES

Staff Supervision

Client Health/Functional Assessment

Care Planning

Signs and Symptoms

Wound care

Medication administration

Client Health Education

Other (See Treatment Plan)

Special policies or certifications

COMMENTS

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Ready to begin your care journey with Legacy Life Home Care Services? Complete the form today or call us at 973-775-9222 for personalized support.

A woman is hugging an older woman on a couch.

HOME
ABOUT US
- WORK WITH US
SENIOR CARE SERVICES
- DAILY LIVING
- SPECIALIZED HEALTH CARE
CARE & SAFETY MONITORING
SERVICE AREA
CONTACT US

Phone: 973-775-9222

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