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MaiCareNow Intake Form
About You
Your name:
*
Email:
*
Phone:
*
What is your relationship to the person needing care?
*
About Your Loved One
First name
*
How old is your loved one?
*
Where does your loved one currently live?
*
Where does your loved one currently live?
A
Lives alone
B
Lives with spouse
C
Lives with family
D
Independent Living
E
Assisted Living
F
Memory Care
G
Skilled Nursing Facility
H
Hospital
I
Rehabilitation Center
J
Other
Understanding the Situation
What changed that led you to seek guidance today?
*
What are your biggest concerns right now?
*
What are your biggest concerns right now?
Safety
Falls
Memory or dementia
Medication management
Medication costs
Home care
Assisted Living
Skilled Nursing
Transportation
Caregiver stress
Financial concerns
Insurance questions
Other
Current Health
Has your loved one been diagnosed with any of the following?
*
Has your loved one been diagnosed with any of the following?
Dementia/Alzheimer’s
Parkinson’s
Stroke
Diabetes
Heart Disease
COPD
Cancer
Kidney Disease
None
Unsure
Has your loved one been hospitalized or visited the Emergency Room in the past 12 months?
*
A
Yes
B
No
C
Unsure
Goals
What would a successful outcome look like for you?
*
How urgent is your situation?
*
How urgent is your situation?
A
Today
B
Within this week
C
Within this month
D
Planning ahead
Is there anything else you’d like us to know?
*
Receive My Personalized Care Guidance