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Run: Senior Services Client Intake and Service Plan

Use this Senior Services Client Intake and Service Plan template to collect client needs, document consent, and assign referrals and scheduled support in one...

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Consent and Privacy Notice

Client consent to collect and use this information for senior services intake and service planning (required)

Yes No N/A

Privacy notice acknowledged (required)

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.

Yes No N/A

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.

Yes No N/A

Preferred contact method (required)

Client Information

Client full name (required)

Date of birth

Collect only if needed to confirm senior program eligibility.

Phone number (required)

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? (required)

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 (required)

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.

Yes No N/A

Referrals and Service Plan

Recommended referrals

Service plan summary (required)

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.

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