Intake form Save a trip, fill out intake here 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: