D.C. Office on Aging and its Senior Service Network Client Intake Form

D.C. Office on Aging and its Senior Service Network

Client Intake Form

Type of Contact (check only one): Site Home Visit Telephone

First name

Last name

Middle initial

Date of birth

Sex Male Female

Street address

Address (cont.)

City

State/Province

Zip/Postal code

Country

Home Phone

Please Check All That Apply and Answer Other When Necessary

Marital Status Never Married Married Widowed Separated Divorced	Household Composition Lives Alone With Spouse With Children With Other Relatives Other	Housing Arrangement Homeowner Renter (Private) Rent Senior Housing Rent Public Housing Group Home or CRF Nursing Home Homeless Other	Ethnicity African American American Indian Asian Origin Hispanic Origin White Other

Income Sources Salary Pension/Retirement Investments No Income Other	Benefits Receiving Medicaid Medicare SSI SSA Food Stamps Veterans Benifits Public Assistance Other	1999 Federal Poverty Guidelines Size of Family Unit 1 Person $8,240 2 Persons $11,060 3 Persons $13,880 4 Persons $16,700 5 Persons $19,520 6 Persons $22,340 Are You At or Below Poverty Level? Yes No
Check one or more of the following instruments and activities of daily lifing which you are NOT ABLE to perform without personal assistance, stand-by assistance, supervision or cues.
Instruments of Daily Living Preparing Meals Shopping for Personal Items Medication Management Money Management Use of Telephone Heavy Housework Light Housework Transportation Ability Able to perform activities without assistance Not required for this client		Activities of Daily Living Eating Dressing Bathing Toileting Transferring to or from a Wheelchair/Bed Walking Able to perform activities without assistance Not required for this client Nutrition Screening Form # Not Required
Information contained on this form will be kept confidential unless disclosure is required by court order for authorized Federal, State, or local Program reporting and monitoring. The client's entitlement to Social Security benefits or other federal or state sponsored benefits shall not be affected by the provision of the aforementioned information.

First name
Last name
Middle initial
Date of birth
Sex	Male Female

Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Home Phone

D.C. Office on Aging and its Senior Service Network

Client Intake Form

�1999 Washington Elderly Handicapped Transportation Services. All Rights Reserved. Last revised: July 11, 1999

�1999 Washington Elderly Handicapped Transportation Services. All Rights Reserved.
Last revised: July 11, 1999