Senior Services Client Intake and Service Plan

Intake form and service plan for municipal senior services covering needs assessment, referrals, and scheduled services.

Consent and Privacy Notice

• Client consent to collect and use this information for senior services intake and service planning
• Privacy notice acknowledged
  I understand this information will be used to assess needs, coordinate services, and document referrals and follow-up. Only authorized staff will access the record.
• Request anonymous submission for general feedback only
  Use only if the submission is for general program feedback. Intake and service planning typically require contact information.
• Preferred contact method

Client Information

• Client full name
• Date of birth
  Collect only if needed to confirm senior program eligibility.
• Phone number
• Email address
• Home address
  Use only if needed for home-based services, transportation, or mailed correspondence.
• Preferred language

Household and Support Information

• Does the client live alone?
• People in the household who can help with daily needs
  Add only the support contacts relevant to service coordination.
• Emergency contact name
• Emergency contact phone

Needs Assessment

• Services requested
• Transportation details
• Meal support frequency
• Home safety concerns
• Areas where the client needs help with daily living
• Urgent risk concerns
  Select any immediate concerns that may require same-day follow-up.

Referrals and Service Plan

• Recommended referrals
• Service plan summary
  Summarize the agreed services, referral actions, and any follow-up steps.
• Scheduled service date
• Scheduled service time
• Follow-up date
• Staff notes
  Use for internal documentation only. Avoid unnecessary PII.