# The Home Care Intake Checklist

Use this checklist when a family, referral partner, or website visitor reaches out about non-medical home care. The goal is to capture enough context for the next person on the team to understand the situation and act without asking the family to repeat everything.

## 1. Caller and decision-maker

- Caller name:
- Caller relationship to client:
- Is the caller the decision-maker? Yes / No / Shared
- Other decision-makers:
- Best callback number:
- Best callback time:

## 2. Client context

- Client name:
- Approximate age:
- City / ZIP:
- Lives alone? Yes / No / Unsure
- Current setting: Home / Hospital / Rehab / Assisted living / Other
- Primary concern:

## 3. Care need

Check all that apply:

- Bathing / grooming / dressing
- Meal preparation
- Medication reminders
- Mobility support
- Companionship
- Dementia or memory support
- Respite for family caregiver
- Post-hospital or recovery support
- Transportation / errands
- Homemaking / light housekeeping
- Other:

## 4. Urgency

- Timeline: Today / This week / This month / Planning ahead
- Trigger event: fall / discharge / caregiver burnout / worsening condition / family travel / other
- Safety concern:
- Is anyone currently helping?

## 5. Payer and decision context

- Expected payer: private pay / insurance / Medicaid / VA / LTC / unsure
- Is the family comparing agencies? Yes / No / Unsure
- Has pricing already been discussed? Yes / No
- Main decision factor: availability / trust / price / location / experience / urgency / other

## 6. Source

- Source: phone / website / Google / referral partner / hospital / social worker / family friend / other
- Referral partner name:
- Partner organization:
- Should the partner receive an outcome update? Yes / No

## 7. Next step

- Next action: callback / assessment / pricing discussion / service-area check / referral follow-up / not a fit
- Owner:
- Due date/time:
- Notes:

## Complete intake test

Before closing the record, ask: could another staff member call this family back with confidence?

If not, capture the missing field before the context disappears.