Elder Care Intake Form:

EAP or Company: Couselor:

Location Department:

EMPLOYEE INFORMATION

Employee Name:

Caller: (if different)

Employee Address:

City:

State:

Zip:

Home Phone: Work Phone:

Cell Phone: E-mail:

ELDER INFORMATION

Relationship: -- SELECT ONE -- Parent In-law Sibling Grandparent Self Other

Current Age:

Current Address & County:

Health Insurance: -- SELECT ONE -- Medicare Medicaid VA Supplemental Other

Health Status:

TYPE OF CARE REQUESTED

-- SELECT ONE -- In-Home Care Nursing Home Adult Day Care Hospice Care Assisted Living Retairment Housing Financial Transportation Respite Care Senior Centers Legal Geriatric Care Manager Other

Nature of Request/Comments: