Client intake

Client Intake Form

Please complete this form as fully as you can. You can fill it out online and submit it securely, or print a blank copy to complete by hand and bring, mail, or fax to us. We typically follow up within two business days.

Or email a completed copy to info@albertsmanor.com

Fax: (772) 212-7033 · Phone: (772) 626-3500

1. Prospective Resident

Full legal name *

Preferred name

Date of birth *

Gender

Current address

Phone number

Marital status

Primary language

2. Responsible Party / Primary Contact

Full name *

Relationship to resident *

Phone *

Email *

Address

Power of Attorney (yes/no, type)

Healthcare Surrogate (yes/no)

3. Emergency Contacts

List 1–2 emergency contacts (name, relationship, phone) *

4. Medical Information

Primary care physician

Physician phone

Preferred hospital

Preferred pharmacy

Current diagnoses / conditions

Allergies (food, medication, other)

Current medications (name, dose, frequency)

Mobility (independent, walker, wheelchair, etc.)

Vision / hearing notes

Cognitive status (alert, mild memory loss, dementia, etc.)

5. Insurance

Medicare number

Medicaid number

Secondary insurance

Policy number

Long-term care insurance (carrier & policy #, if any)

6. Care Needs

Help needed with: bathing, dressing, eating, toileting, medication management, transfers, etc.

7. Dietary Preferences & Restrictions

Dietary needs, restrictions, food preferences, dislikes

8. Personal Background

Religious preferences / spiritual practices

Hobbies and interests

Life history / things we should know (career, family, military service, etc.)

9. Behavioral / Mental Health Notes

Anything we should know about mood, behavior, sleep patterns, or triggers

10. Move-In Details

Desired move-in date

Room preference (private / shared / no preference)

How did you hear about us?

11. Acknowledgments

I confirm the information provided is accurate to the best of my knowledge.I understand Albert's Manor performs background checks on both staff and clients as part of the admission process.I consent to sharing the health and background information above with Albert's Manor for the purpose of assessing care needs.

12. Signature

Name of person completing this form *