Client Admission Form

Instructions for Use:

This form is to be completed upon initial client enrollment and updated whenever there are significant changes in the client’s condition, care needs, or contact information.

Guidelines:

All applicable sections must be completed. If a field is not applicable, indicate "N/A."
All information must be accurate, complete, and verified with the client or legal guardian.
Confidentiality must be maintained in accordance with Abid Health Care’s Confidentiality Policy and HIPAA regulations.
Original completed forms shall be filed in the client’s record; copies may be provided to authorized personnel as needed.
Any changes or updates must be recorded and signed by the staff completing the update.
This form serves as a reference for care planning, service provision, and emergency preparedness.

Section 1: Client Demographics

Full Legal Name

Preferred Name/Nickname

Date of Birth

Age

Gender

Other

Social Security Number

Home Address

City

State

ZIP Code

Primary Phone Number

Alternate Phone Number

Email Address

Preferred Method of Contact

Other

Primary Language

Interpreter Required?

Marital Status

Emergency Contact Name

Relationship

Phone Number

Alternate Phone Number

Section 2: Responsible Party / Legal Guardian (if applicable)

Name

Address

Email Address

Relationship to Client

Phone Number

Legal Authority (Power of Attorney, Guardian, etc.):

Documentation Provided

Upload Your Documents

Section 3: Medical and Health Information

Primary Care Physician

Preferred Hospital

Past Medical History

Physician Phone

Allergies (Medications, Foods, Environmental)

Other

Specialist Physicians

Current Medications (include dosage, frequency)

Immunization Status

Primary Health Insurance

Insurance ID/Policy Number

Cognitive Status

Other

Sensory Impairments

Other

Insurance ID/Policy Number

Advanced Directives / Living Will

Upload Here

Behavioral Health / Mental Health Conditions

Secondary Health Insurance

DNR (Do Not Resuscitate) Status

Mobility Status

Other

Communication Needs

Section 4: Service Needs Assessment

Reason for Admission

Preferred Service Times

Dietary Restrictions / Preferences

Cultural / Religious Considerations

Requested Services

Frequency of Services

Special Equipment Needed

Communication / Language Preferences

Other

Section 5: Safety Assessment

Fall Risk

Smoke Detectors Present

Other Safety Concerns

Home Hazards Identified

Fire Extinguisher Present

Emergency Exits Accessible

Pets in the Home

Other

Section 6: Consent and Authorization

Consent for Services: I hereby authorize Abid Health Care LLC to provide the services requested in this intake form.

HIPAA Release: I understand that my personal health information will be protected according to HIPAA regulations and may only be shared with authorized personnel.

Emergency Medical Treatment: In the event of an emergency, I authorize Abid Health Care LLC to contact emergency medical personnel and/or transport me to the nearest hospital.

Medication Administration: I authorize Abid Health Care LLC staff to assist or administer prescribed medications according to my care plan.

Photographs / Media Release: □ Yes □ No – I consent to photographs for care documentation only.

Signatures:

Client / Legal Guardian

Sign Here

Signature

Sign Here

Date

Intake Staff

Signature

Sign Here

Date

Supervisor / Administrator

Signature

Sign Here

Date

Section 7: Intake Notes / Additional Observations

Textarea

Section 8: Follow-Up / Next Steps

Care Plan Development – Responsible Staff

Service Scheduling – Responsible Staff

Equipment / Supply Arrangement – Responsible Staff

Staff Assignment – Responsible Staff

Follow-Up Assessment – Responsible Staff

Date