Client Intake Form

Non-Medical | In-Home Support

Click Here: Registration Form

1. CLIENT INFORMATION

2. PRIMARY CONTACT / RESPONSIBLE PARTY

3. SERVICES REQUESTED

(Non-Medical Only – Check all that apply)

• PERSONAL CARE (ADLs)

☐  Bathing / Shower assistance

➡ How often?

☐ Daily  ☐ 2–3x/week  ☐ Weekly  ☐ As needed

Details: _________

☐  Personal hygiene & grooming

➡ How often?

☐ Daily  ☐ 2–3x/week  ☐ Weekly  ☐ As needed

☐ Dressing assistance

➡ How often?

☐ Daily ☐ 2–3x/week ☐ Weekly ☐ As needed

☐ Nail care (painting/grooming if requested)

➡ How often?

☐ Weekly ☐ Bi-weekly ☐ Monthly ☐ As requested

☐ Hair care (brushing/light styling – non-clinical)

➡ How often?

☐ Daily ☐ 2–3x/week ☐ Weekly ☐ As needed ☐ Mobility assistance (non-medical)

➡ How often?

☐ Each visit ☐ As needed ☐ Morning routine

➡ How often?

☐ Daily ☐ Selected days: _____

☐ Bedtime routine

➡ How often?

☐ Daily ☐ Selected days: _____

☐ Skin care & comfort support

➡ How often?

☐ Each visit ☐ As needed

• COMPANION & HOME SUPPORT SERVICES

☐ Companionship & conversation

➡ How often?

☐ Each visit ☐ Daily ☐ Weekly

☐ Emotional support & listening presence

➡ How often?

☐ Each visit ☐ As needed

☐ Reading (Bible, devotionals, books)

➡ How often?

☐ Each visit ☐ Weekly ☐ Upon request

☐ Light meal preparation

➡ How often?

☐ Each visit ☐ Daily ☐ Selected days: _____

☐ Light housekeeping (client-related areas)

➡ How often?

☐ Each visit ☐ Weekly ☐ Bi-weekly

☐ Laundry assistance

➡ How often?

☐ Weekly ☐ Bi-weekly

☐ Errands / grocery support

➡ How often?

☐ Weekly ☐ Bi-weekly ☐ Monthly

☐ Appointment accompaniment (non-medical)

➡ How often?

☐ As scheduled

• CHAPLAINCY & SPIRITUAL CARE

☐ Prayer

➡ How often?

☐ Each visit ☐ Upon request ☐ Occasionally

☐ Scripture reading

➡ How often?

☐ Each visit ☐ Weekly ☐ Upon request

☐ Faith-based encouragement

➡ How often?

☐ Each visit ☐ As needed

☐ Emotional & spiritual support

➡ How often?

☐ Each visit ☐ As needed

☐ End-of-life presence (non-clinical)

➡ How often?

☐ As requested

☐ Support for family/caregivers

➡ How often?

☐ As needed

4. SERVICE SCHEDULE

Preferred Days of Service:

☐ Monday ☐ Tuesday ☐ Wednesday ☐ Thursday ☐ Friday ☐ Saturday ☐ Sunday

Hours per Visit:

☐ 2 hrs ☐ 4 hrs ☐ 6 hrs ☐ Other: ___

Total Visits Per Week:

☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ Other: ___

5. HEALTH & SAFETY (NON-MEDICAL)

(same as before)

6. CONSENT & ACKNOWLEDGMENT

(same as before)

GRACEFUL GUIDANCE

Individualized Care Plan (UPDATED)

Including Frequency & Schedule

Client Name: _________

Start Date: _________

Review Date: _________

1. CARE GOALS

(same as before)

2. PERSONAL CARE PLAN WITH FREQUENCY

Care Task

Frequency

Notes

Bathing/Shower

☐ Daily ☐ 2–3x/week ☐ Weekly

Grooming/Dressing

☐ Daily ☐ As needed

Nail Care

☐ Monthly ☐ As requested

Hair Care

☐ Daily ☐ Weekly

Mobility Support

☐ Each visit ☐ As needed

Morning Routine

☐ Daily ☐ Selected days

Bedtime Routine

☐ Daily ☐ Selected days

3. COMPANION & HOME SUPPORT PLAN

Service

Frequency

Notes

Companionship

☐ Each visit

Reading/Conversation

☐ Weekly ☐ Each visit

Meal Prep

☐ Daily ☐ Selected days

Light Housekeeping

☐ Weekly ☐ Bi-weekly

Laundry

☐ Weekly ☐ Bi-weekly

Errands

☐ Weekly ☐ Monthly

4. SPIRITUAL CARE PLAN

Service

Frequency

Notes

Prayer

☐ Each visit ☐ Upon request

Scripture Reading

☐ Weekly ☐ Upon request

Emotional Support

☐ Each visit

5. COMMUNICATION & UPDATES

Family Updates:

☐ Weekly ☐ Bi-weekly ☐ Monthly ☐ As needed

Preferred Method:

☐ Phone ☐ Text ☐ Email

6. CARE NOTES & OBSERVATIONS

(Caregiver use)

7. REVIEW & SIGNATURES

(same as before)

DISCLAIMER! 

Graceful Guidance provides non-medical personal care, companionship, and spiritual support only and does not replace medical or nursing services.