Intake form

MEMBER/PATIENT NAME:

Date of Intake:

Your Email:

Name:

DOB:

Address:

City:

State:

Zip:

Diagnosis: Medical conditions:

Current medication (if applicable)

Allergies:

Assistive Devices?

Legal Competency Status:
Own guardianPending guardianshipHas a legal guardian

Appointed guardian name and phone number:

DDS Eligible
YesNo

If yes, Service Coordinator:

Are you receiving any other services such as; PCA, Home Health Aide, etc.

Are you coming from another AFC agency?
YesNo

If yes, name of agency

Do you attend any program/work?
Contact information:

Schedule:

PHYSICIAN(S):

NPI

Name of PCP:

Phone and Fax:

Address of PCP:

Other Physicians that’s treating this person: