❤️ Companion Care

Providing friendly conversation, emotional support, and meaningful interaction to reduce loneliness and improve quality of life.

🍽️ Meal Preparation

Preparing nutritious meals and snacks while following dietary preferences and needs.

🧹 Light Housekeeping

Helping maintain a clean and comfortable living space including laundry, dishes, and general tidying.

🚗 Errand Assistance

Helping with grocery shopping, prescription pick-ups, and everyday errands to support independence.

👵 Personal Care Assistance

Helping with daily living activities such as dressing, grooming, mobility support, and hygiene assistance.

💬 Family Support & Updates

Keeping families informed and reassured about their loved one’s well-being.

Bailey’s Compassion Care – Client Intake Form

Client Information

  • Full Name: ______________________________

  • Date of Birth: ___________________________

  • Gender: _________________________________

  • Address: ________________________________

  • City/State/Zip: _________________________

  • Phone Number: __________________________

  • Email Address: __________________________

Primary Contact / Responsible Party

  • Name: __________________________________

  • Relationship to Client: __________________

  • Phone Number: __________________________

  • Email Address: __________________________

  • Address (if different): _________________

Emergency Contact

  • Name: __________________________________

  • Relationship: ___________________________

  • Phone Number: __________________________

  • Alternate Phone: ________________________

Medical Information

  • Primary Physician Name: __________________

  • Physician Phone Number: ________________

  • Diagnosis / Medical Conditions:

  • Allergies:

  • Current Medications (Name & Dosage):

Care Needs (Check All That Apply)

☐ Personal Hygiene / Bathing
☐ Dressing Assistance
☐ Meal Preparation
☐ Medication Reminders
☐ Mobility / Transfer Assistance
☐ Companionship
☐ Dementia / Alzheimer’s Care
☐ Light Housekeeping
☐ Transportation / Errands
☐ Fall Prevention / Safety Monitoring
☐ Other: __________________________

Mobility Status

☐ Independent
☐ Walker
☐ Wheelchair
☐ Bed Bound
☐ Requires Assistance

Mental & Cognitive Status

☐ Alert & Oriented
☐ Mild Memory Loss
☐ Dementia / Alzheimer’s
☐ Confusion Episodes
☐ Behavioral Concerns
(Explain if needed)

Daily Routine / Preferences

  • Preferred Wake Up Time: ______________

  • Meal Preferences / Restrictions: _______

  • Hobbies / Interests: _________________

Insurance / Payment Information

  • Insurance Provider (if applicable): __________

  • Policy Number: ____________________________

  • Private Pay / Other: ________________________

Consent & Authorization

I authorize Bailey’s Compassion Care to provide non-medical home care services and acknowledge information provided is accurate.

Client/Guardian Signature: _______________________
Date: ___________________

Office Use Only

  • Intake Completed By: __________________

  • Service Start Date: ____________________

  • Care Plan Created: _____________________