Intake-Form

Participant Information

First Name *

Middle Name

Last Name *

Date of Birth *

Social Security Number

Gender *

Male Female Other

Home Address *

City *

State *

Zip Code *

Phone Number *

Email Address

Primary Language *

Marital Status

Religion

Ethnicity

Emergency Contact Information

Primary Emergency Contact

Full Name *

Relationship *

Phone Number *

Alternate Phone

Address

Secondary Emergency Contact

Full Name

Relationship

Phone Number

Alternate Phone

Medical Information

Primary Care Physician *

Physician Phone *

Medical Diagnosis/Conditions *

Current Medications *

Allergies (Food, Medication, Environmental) *

Mobility Status *

Hearing Status

Vision Status

Dietary Restrictions/Preferences

Insurance Information

Primary Insurance

Insurance Company *

Policy Number *

Group Number

Policy Holder Name

Insurance Phone

Secondary Insurance (if applicable)

Insurance Company

Policy Number

Group Number

Medicare *

Yes No

Medicare Number

MassHealth *

Yes No

MassHealth Number

Service Information

How did you hear about us? *

Preferred Start Date *

Days of Service Requested *

Monday Tuesday Wednesday Thursday Friday

Transportation Needed? *

Yes No

Transportation Notes

Goals for Participation

Special Needs or Accommodations

Consent and Signature

I hereby authorize:

Soley Leve Adult Day Health LLC to provide adult day health services to the participant named above.
The release of medical information to and from healthcare providers as necessary for care coordination.
Emergency medical treatment if I cannot be reached and immediate care is required.
The use of photographs/videos of the participant for program documentation and promotional materials (unless otherwise noted).

I certify that:

All information provided is true and complete to the best of my knowledge.
I understand that false or misleading information may result in termination of services.
I have read and understand the program policies and agree to abide by them.

I do NOT wish to have photographs taken

Check if you opt out

Name of Person Completing Form *

Relationship to Participant *

Signature (Type Full Name) *

Date *

Consumer Intake Form

Primary Emergency Contact

Secondary Emergency Contact

Primary Insurance

Secondary Insurance (if applicable)