A non medical home care intake form built around the household

Onboarding a household, not evaluating a patient

Non-medical home care usually starts with a phone call from somebody who is worried, generally about a parent, and often from another city. What happens next depends almost entirely on the document your office fills in during that call — and most of what is available online is the wrong document: static PDFs, packets adapted from nursing assessments, and template pages that want an email address before they show you anything. A non medical home care intake form has a fundamentally different job from a clinical one. Non-medical home care is companionship and conversation, light housekeeping, laundry, meal preparation, shopping and errands, transport to appointments, medication reminders, and personal care such as help with bathing, dressing, grooming and moving safely around the house. It is not skilled nursing and it is not therapy. Nobody using this form is assessing a wound, changing a dressing, administering a medication or writing a plan of care — a caregiver reminds a client that it is ten o'clock and the pills are in the kitchen, which is a different act with a different meaning. This preset is written for that work, opens populated and ready, and is editable throughout, with a US Letter PDF available the moment the page loads and no account or email wall anywhere.

• Built for HIPAA-compliant workflows

• Free to start — 50 patient actions each month

What a home care client intake form usually covers

A home care client intake form has two subjects rather than one, and this preset is structured accordingly. The client: name, date of birth, the address where care will be delivered, phone, who else lives in the house, primary language, and the physician's name and number held as a contact rather than as a clinical record. Then the responsible party, because the person completing this form is very often not the client — the adult daughter arranging the service, her relationship to him, her address and best number, who holds power of attorney or a healthcare proxy if anyone does, who signs the service agreement, who receives the invoice, and who to call first in an emergency and who second. Then the service request itself: which days, which hours, when it starts, and whether it is ongoing or covering a particular stretch such as a recovery at home. Then support needs, routine and preferences. Then the household details a caregiver needs before the very first visit. Every part of it is recorded as the client or the family describes it, in their words.

Assistance as it is described, not as it is scored

The support section is where borrowed clinical templates do the most damage, because they arrive with rating scales attached and an implied authority nobody in the office has. This preset keeps the familiar categories and drops the scoring entirely. Everyday personal care — bathing, dressing, grooming, toileting, eating, moving between bed and chair, walking and stairs — is recorded as the level of help the family says is needed, with a line to describe it in their own words. Household and community tasks — meals, laundry, light housekeeping, shopping, transport, appointments, phone calls and bills, medication reminders — the same way. He can dress himself but needs someone to hand him things and stay nearby is worth more to a caregiver arriving on Monday morning than any number between one and four, and it makes no claim to be an assessment. The form produces no score, no functional level, no care plan and no judgement about whether a client is suitable for service. Those decisions belong to your agency, and where nursing input is genuinely required, to a licensed clinician.

The routine, the front door, and what not to ask

Two sections make this form worth printing, and neither appears on a clinical template. The first is the day: what time he likes to get up, that coffee comes before anything else, when the programme he watches is on, when he naps, what he eats and what he will not touch, the names of the grandchildren who ring on Sundays, the topics that upset him, and how he prefers to be addressed. That is what turns a stranger into somebody he is glad to see on Thursday. The second is access, and it is the difference between a first shift that starts on time and one that starts with a phone call from the driveway: which entrance, the door code or where the key is kept, parking, the stairs, the dog and its name, the alarm, the neighbour with a spare key, and where the laundry and cleaning supplies actually live. Set against that, ask what the medical history block is really for. If your caregivers do not act on a diagnosis, your agency has no operational reason to hold it — collect allergies, dietary needs, mobility limitations and emergency contacts, and leave the rest with the people who do act on it.

Edit it, then download exactly what you built

Rename the form, rewrite any question in your own language, mark fields required or optional, and add, duplicate, reorder or remove whole sections. Agencies diverge fast from one starting point: a companion-care service strips the personal care block, a dementia-focused agency expands routine and preferences and adds safety questions written by its own lead, and an agency that hands the document to families ahead of an in-home visit shortens it to a single page. A home care intake form template you cannot change is just somebody else's paperwork, which is why every label on this one is yours. The default home care intake form PDF is ready as soon as the page loads, and after any change a new PDF is generated from your current version rather than the original, so the pack you print for the binder matches what is on screen. It sets on US Letter with real writing space, breaks cleanly across pages, stays legible photocopied, and reset restores the original preset whenever you want to begin again.

An eleven-caregiver agency covering two counties

An agency with eleven caregivers across two rural counties rebuilt its intake in a morning. They split the form visibly into the client and the person arranging the care, having realised that most enquiries come from an adult child several hours away while their old form had one contact line. They added the access block after a caregiver spent twenty minutes outside a locked house at seven in the morning while the daughter's phone went to voicemail. They rewrote the personal-care section to record what the family actually says rather than a one-to-four scale copied from a nursing form nobody in the office was qualified to complete. They deleted a full page of medical history and kept allergies, dietary needs and mobility. And they added a free-text box headed a typical day, which their scheduler now reads aloud to a caregiver before every first shift. Same information, half the pages, and first visits that begin at the front door instead of on the phone.

What your agency and its attorney own

Be clear about what this document is and is not. It is an original form written for this page, not a copy of any state agency, association or published form — and where your state or your association publishes one that must be used, use theirs. It does not satisfy any state's licensing, registration or home-care regulations, and it is not a service agreement, a disclosure statement or a client contract: requirements for non-medical home care differ substantially from one state to the next and they change, so they belong to your agency and its attorney to get right rather than to a template. It makes no determination about eligibility, about suitability for service, or about whether any programme, plan or payer will cover the hours. Have your agency owner and attorney review the whole document before it goes into use, and a licensed clinician review anything that touches health information. Because this builder is public, build the blank form here rather than entering a real client's details, and nothing typed into it is sent to analytics either way.

When the clipboard starts costing more than it saves

Whether HIPAA applies to your agency at all depends on how it operates and who it bills, which is a question for your attorney rather than for a template — the HHS guidance for professionals is the place to start reading. Client information deserves the same care either way, and DocRepute is HIPAA-focused and built for HIPAA-compliant workflows, with BAA availability planned at launch. Take the PDF today. When the paper starts costing you more than it saves, the same intake can run digitally instead: a link the family completes before the first visit, and a structured record your scheduler reads rather than a page somebody has to re-key at nine at night. DocRepute is in early access ahead of launch and free to start on 50 action credits a month — creating, editing and publishing forms and surveys costs nothing at all, and a credit is used only when someone completes a regular submission or a standard survey. There is no AI on the free path. If your agency also arranges skilled nursing or therapy at home, that side of the business needs its own paperwork, and the links below go straight to it.