Support At Home

Support at Home Voucher Program Intake Form

Printing Instruction: Please complete form first and select "Landscape" for the Layout before printing this form if you intend to fax it in.

How did you hear about Institute on Aging?*

Would you like to receive our newsletter?*

CLIENT INFORMATION

Client Name*

First Name

Last Name

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Best Contact Number*

Email Address*

If you would like status updates on your referral, please enter your email. If you do NOT wish to receive updates or do not have an email, enter N/A.

Date of Birth*

Race/Ethnicity*

Marital Status*

Sexual Orientation or Identity*

Gender*

What was your sex at birth?*

If Sexual Orientation or Identity is not listed, please specify:

If Gender is not listed, please specify:

Language*

Speaks English*

REFERRAL SOURCE INFORMATION

Referral Source Name*

First Name

Last Name

Best Contact Number*

Agency*

Enter N/A if this is a self or family/relative referral.

Relationship to Client*

Email Address:*

If you would like status updates on this referral, please enter your email. If you do NOT wish to receive updates, enter N/A.

Is the prospective client aware of the referral?*

Can the prospective client be reached directly by phone?*

Responsible Party's Name*

If the Referral Source or Client is unreachable, please indicate who is the client's responsible party.

Relationship to Client*

Responsible Party's Best Contact Number*

CLIENT FINANCIAL INFORMATION

Do you receive Medi-Cal?*

If yes, please contact Institute on Aging for more information.

If no, please indicate the reason:*

High share of cost Have not applied Income or assets too high

Social Security #:

By providing the client's SSN, this will help expedite the REFERRAL process only, NOT enrollment.

Do you have GREATER than $40,000 in household assets (excluding one house and one car)?*

If your assets are greater than $40,000, please contact Institute on Aging for more information.

How many people are in your Household?*

Include yourself, spouse, minor children or person(s) that can be claimed on your taxes.

Monthly Household Income?*

Include yourself, spouse, minor children or person(s) that can be claimed on your taxes.

Total Liquid Assets for Household*

Excluding one house and one car

Support At Home provides Voucher funding for Clients that are able to contribute a portion of the home care cost (a Copayment). Are you willing to pay a Copayment?*

Yes No

Copayment amounts are sliding scale based on an assessment. You will know your Copayment amount after you complete an assessment and before you decide to enroll.

Instrumental/Activities of Daily Living

Select the Level at which the individual can safely complete the activity

Independent: Manages activity without human help (Devices OK), Verbal: Requires reminders, encouragement, direction (up to 25% assistance), Some Human Help: Requires supervision, occasional help (25-50% assistance), Lots of Human Help: At risk without a lot of help (50-75% assistance), Dependent: Unable to manage on their own (75-100% assistance), Paramedical: Requires a trained medical proffesional to manage.

Eating*

Dressing*

Transferring*

Body Hygiene*

Bowel & Bladder Care*

Medication Management*

Personal Hygeine*

Stair Climbing*

Mobility Indoor*

Mobility Outdoor*

Housework*

Laundry*

Shopping & Errands*

Meal Prep & Cleanup*

Transportation*

Communication*

Recent Health Information

Recent falls in the last 3 months?

If yes, how many?

If no, enter 0

Any hospitalizations (within last 3 months)?

If yes, how many?

If no, enter 0

Any ER visits WITHOUT being admitted to the hospital? (within last 3 months)?

If yes, how many?

If no, enter 0

System Requirements

While our intake forms will work with older browsers, such as Internet Explorer 8, we do recommend keeping your browser updated to the latest version for the best possible experience. You can download the latest version of IE here and the latest version of Firefox here. If you're using Internet Explorer 8 or greater, please make sure Compatibility View is turned off. However, due to many problems reported with Internet Explorer, we highly recommend using a different browser.