Homemaking Client Application
-
Upload
mia-jackson -
Category
Documents
-
view
14 -
download
0
description
Transcript of Homemaking Client Application
Homemaking Client Intake Form Date: ____________________________
Contact Person: ______________________________________ Contact address: _________________________________________________________ Contact Phone #: _____________________________
Client Name: _________________________________________ (individual needing services)
Address: __________________________________________________ City/State/Zip: ________________________________________ Birthdate: _________________________ Phone Number: _______________________________ Email: _____________________________________ Social Security #: ____________________________ Ethnicity: ___ White ___ American Indian ___Hispanic ___African American ___Asian ___Declined Living Situation: ___ Own Home ___ Rental Unit ___ Friend/Relative ___ Homeless ___ Assisted Living ___ Long Term Care Facility ___ Halfway House Currently Living With: ___ Spouse/Partner ___Alone ___Group Setting (non relative) ___ Child ___ Parent-Adult ___ Parent-Child ___ Other (non spouse/partner) Marital Status: ___ Married ___ Divorced ___ Separated ___ Not Married/Single ___ Widowed Employment Status: ___ Full Time ___ Part Time ___ Not Employed ___ Self Employed
Check all sources of income that are received by members of your household: _____ Salary or wages ____ General Assistance ______ Retirement, Pension ____ Food Stamps
_____ Alimony/Child Supp. ____ Unemploy. Comp _____ MSA ____ Housing
_____ Social Security _____ TANF (AFDC,MFIP) ______ Interest/other ____ Medical Aide
_____ Self Employment _____ SSI ______ No income ____ Veteran’s Benefits
Does the client have a disability? yes no ***if yes, see next page*** Are they certified disabled? in process no SSA SMRT (State Medical Review Team) Assistance: monthly income_____________________ # in household_____ primary language_________________ Veteran? yes no Veteran Relation? self spouse Active Duty Service: Korean War Iraq/Afghanistan Vietnam WWII MN Benefits: yes no PMI #________________________________ Federal Benefits: SSA SSI SSDI SSI & SSDI Social Security Number # __________________________________ Medicare: yes no Medicare # _____________________________________ What is the client’s need or concern? (Please explain) _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ How often:_______________________________________________ Confirm Income (Tax Return)_____________________________________________ 2/2011
Specific Disability Information – Physical
Amputation Back Problems Carpal Tunnel
Cerebral Palsy Chronic Pain GENERAL
Muscular Dystrophy Obesity Paralysis
Paraplegic Parkinson’s Quadriplegic
Scoliosis Spina Bifida Spinal Cord Injury
Stroke
Specific Disability Information – Chronic Illness
ALS Arthritis Asthma
Cancer COPD Diabetes
End State Renal Disease Environmental Sensitivity Epilepsy
Fibromyalgia GENERAL Heart Disease
High Blood Pressure HIV/AIDS Lupus
Multiple Sclerosis Neuropathy Polio
Specific Disability Information – Cognitive
GENERAL Autism Developmental Disability
Fetal Alcohol Syndrome Learning Disability Memory Loss
Traumatic Brain Injury
Specific Disability Information – Psychiatric
Anxiety Disorder ADD/ADHD Bipolar Disorder
Depression DID Eating Disorder
GENERAL OCD Post Traumatic Stress
Schizophrenia Social Phobia
Specific Disability Information – Chemical Dependency
Alcoholism Drug Addiction GENERAL
Specific Disability Information – Hearing
Deaf GENERAL Hearing Loss
Specific Disability Information – Visual
Blind GENERAL Vision Loss
Specific Disability Information – Speech
GENERAL Non-Verbal Speech Impairment
Specific Disability Information – Temporary
GENERAL Short-term Disability