The Home Care Client Intake Form, Field by Field

What Belongs on a Home Care Client Intake Form

The call comes in on a Tuesday afternoon: a new client fell over the weekend, the family is scrambling, and the agency needs to start service by Thursday. The coordinator pulls up the intake packet — and realizes the emergency contact field was left blank three weeks ago during a rushed phone intake, the allergy line says "TBD," and nobody wrote down who actually holds power of attorney. Now there's a hospital discharge planner on the phone asking questions the office can't answer.

This is the moment a home care client intake form either earns its place in the file or reveals itself as a liability. A good intake form isn't paperwork for its own sake — it's the single document every other part of the care plan depends on: the emergency contact tree, the functional baseline, the medication list, the service agreement, the consent to share information with a family member. Get the fields right at intake, and everything downstream is easier to build, easier to defend at a licensing review, and easier to hand to a new caregiver on day one.

Below is a field-by-field walk-through of what a thorough home care client intake form should capture, and why each section earns its place. For a broader look at the surrounding process — first call through first shift — see the new client onboarding checklist and the deeper dive on intake best practices.

Client and Household Identifying Information

Every intake form starts here, and it's easy to treat as an afterthought — which is exactly how gaps creep in. At minimum, capture:

• Full legal name, preferred name, date of birth
• Current address, including entry instructions (gate codes, lockboxes, parking notes)
• Primary phone and a backup contact method
• Preferred language, and any communication accommodations (hearing, vision, cognitive)
• Referral source (hospital discharge, family, physician, self-referral) — useful for both follow-up and for understanding how urgent the intake is

This section also sets the tone for everything after it. A client referred by a hospital discharge planner after a fall has a different urgency profile than a client whose adult child called after noticing gradual decline over months. Note that context here so the coordinator building the actual plan doesn't have to reconstruct it later.

Emergency Contacts, Family Roles, and Decision-Makers

This is the section most likely to be rushed on a first call — and the one most likely to matter in a crisis. A home care client intake form should distinguish between several roles that are easy to conflate:

• Emergency contact — who gets called first if something happens during a shift
• Primary decision-maker / power of attorney — who has legal authority to make care decisions, and whether that authority is documented
• Family members with a general update interest — who wants to be kept in the loop but has no decision-making authority
• Physician and pharmacy contacts — for coordination, not for clinical direction

Family caregiving context is worth keeping in mind here: an estimated 63 million people in the US were serving as family caregivers as of 2025, roughly one in four adults, according to AARP and the National Alliance for Caregiving. Many of them are juggling caregiving with work and their own households, which is exactly why a clear, unambiguous contact hierarchy on the intake form — not a vague list of "family" — saves confusion when a decision needs to be made quickly.

The emergency contact field is the one part of the intake form that gets tested under the worst possible conditions. Treat it accordingly.

Functional Baseline: Where ADL and IADL Fields Fit

The intake form is also where the functional picture starts. This doesn't need to be a full clinical assessment — but it should capture enough of a baseline that the care plan built afterward isn't starting from zero.

Two long-standing, public-domain frameworks are worth building this section around:

The Katz Index of Independence in Activities of Daily Living, published in 1963, scores six basic self-care functions: bathing, dressing, toileting, transferring, continence, and feeding. Each is scored as independent or dependent, and the six combine into a simple composite — a score of 6 generally reflects full function, 4 reflects moderate dependency, and 2 or below reflects severe dependency, per the Hartford Institute for Geriatric Nursing's widely used "Try This" guidance. The framework is reproducible for not-for-profit educational use with attribution to the Hartford Institute.

The Lawton-Brody Instrumental Activities of Daily Living Scale, published in 1969, covers eight more complex domains: using the telephone, shopping, food preparation, housekeeping, laundry, mode of transportation, responsibility for medications, and ability to handle finances. It scores on a 0–8 range, with 8 representing full independence.

An intake form doesn't need to run the full scored assessment on day one — that belongs in the care plan itself, ideally timestamped so a licensing reviewer or a family member can see exactly when the baseline was recorded and how it changes over time. But intake should flag, at minimum, which of these areas already look like concerns, so the person building the plan knows where to start. For the full picture of how a baseline functional snapshot feeds into an ongoing plan, see the complete guide to the home care plan.

Home Environment and Safety Screening Fields

Falls are the single most common reason a home care intake turns urgent. According to the CDC, roughly one in four adults age 65 and older — more than 14 million people — falls each year, and falling once roughly doubles the risk of falling again. That risk profile is exactly why a home care client intake form should include a basic home safety screen, not just a health history:

• Stairs, and whether grab bars or rails are present
• Bathroom hazards (tub/shower access, non-slip surfaces)
• Lighting, especially in hallways and at night
• Loose rugs, cords, or clutter creating trip hazards
• Wandering risk, if cognitive decline is a factor
• Pets, and whether they create a tripping or safety concern

This section doesn't need to be exhaustive at intake — a fuller scored home-safety assessment belongs in the care plan itself — but capturing the obvious hazards up front means the first caregiver walking into the home isn't discovering them cold.

Medication List Fields (and Their Limits)

The medication section of an intake form should capture what's being taken, the general schedule, and known allergies — enough for a caregiver to help a client stay organized and to flag a missed dose or an obvious discrepancy. It's worth being explicit about what this section is not: it is a reminder-and-organization record, not a clinical medication administration record, and it should never be used as the basis for dosing decisions. Any change to a medication regimen belongs in the hands of the client's physician or pharmacist, not the intake form.

Fields worth including:

• Medication name, dose, and general time of day
• Known allergies and past adverse reactions
• Prescribing physician and pharmacy contact
• Whether a family member or the client self-manages medications, or whether reminders are needed

Consent, Authorization, and the Service Agreement Layer

The final section of the intake form is where the paperwork becomes legally load-bearing: consent to provide services, authorization to share information with named family members or medical providers, and the service agreement itself covering scope of care, billing terms, and cancellation policy. This is also the section most agencies get wrong by treating it as boilerplate rather than something the client and family actually understand and sign knowingly.

A few things worth calling out explicitly on the form:

• Who is authorized to receive updates about the client's condition, and who is not
• What happens if the client wants to change or revoke that authorization later
• The specific services covered under the agreement, so there's no ambiguity later about what was promised versus what was billed

For a closer look at building this section correctly, see the dedicated breakdowns on the service agreement template and the consent and authorization form.

Because intake forms often move between the agency office, the client's home, and family members in different locations, it's worth knowing how the form itself is stored. A structured system built around a zero-PHI architecture — where client and plan data is never stored server-side by design — removes one layer of exposure from that handoff, though every agency should still confirm its own obligations under its state licensing rules or, in Canada, under provincial privacy legislation like Ontario's PHIPA, with its own counsel or privacy officer.

Building the Form Once, Instead of Reinventing It Per Client

A home care client intake form that covers identifying information, emergency contacts and decision-makers, a functional baseline, a home safety screen, a medication list scoped correctly, and a clear consent and service agreement section isn't complicated to build — but it is easy to build inconsistently, one client at a time, with fields quietly dropped under time pressure. The Client Intake & Onboarding Kit packages this structure as a ready-to-use starting point, so the fields above are built in once rather than reconstructed from memory on every new intake call.