Military Intake Form Step 1 of 9 11% Care TypeEmergency Child CareDeployment RespiteClient TypeNew (Intake Form Needed)Existing (New Scheduling Request) Existing Client - New Scheduling RequestClient Name First Last Desired Date Date Format: MM slash DD slash YYYY Notes New Client DetailsClient Name* First Last Gender*MaleFemaleOtherDate of Birth* Date Format: DD slash MM slash YYYY Who does the client live with? Mother Father Grandparent(s) Relative(s) Family Friend Other Other:*Home Address* Street Address City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Guardian & Contact DetailsGuardian Name First Last Main Phone NumberSecondary Phone NumberEmail Relationship Add an additional Parent/Guardian? Additional Guardian DetailsGuardian Name First Last Main Phone NumberSecondary Phone NumberEmail RelationshipSecondary Contact Phone NumberRelationship Emergency Contact DetailsAdditional Emergency Contact DetailsFirst NameLast NameRelationshipPrimary Phone NumberSecondary Phone NumberEmail Address Please have 2 emergency contacts listed (In addition to guardian details) Medical Information & Care GoalsOfficial diagnosis/diagnoses or query conditions (medical/behavioural):Recurring or ongoing health issues (i.e. allergies, compromised immunity, rashes, pressure sores, etc.)Diagnosed or query mental health/behavioural conditions:(i.e. depression, Autism Spectrum Disorder, anxiety, Oppositional Defiance Disorder, substance use, etc.)Please describe client's current behaviours:(i.e. frequent mood changes, poor eating, poor judgement, sleeping problems, anxious, agitation, fear, aggression, depression, etc.)Are there any difficulties with vision/hearing/swallowing/mobility/speech?If so, please explain the level of assistance.Are there any incontinence issues?Please list any regular medications or supplements along with dosage and administration times and reason for medication: Attach a Medication Administration Record (MAR)? FileDoes the client need medication reminders?If so, please list times and frequency. Activities of Daily Living (ADLs)Does the client require assistance with toileting?YesNoDoes the client require assistance with eating?YesNoDoes the client require assistance with ambulation?YesNoDoes the client use a mobility aid?YesNoIs the client a fall risk?YesNoDoes the client require transfer assistance?YesNoAre there any transfer aids in use?(i.e. gait belt, hoyer lift, etc.)YesNoDoes the client require assistance with bathing/showering?YesNoDoes the client require assistance with grooming/dressing?YesNoDoes the client require assistance with sleeping?YesNoInstrumental Activities of Daily Living (IADLs)Does the client require assistance with meal preparation?YesNoDoes the client require assistance with medication administration?YesNoWhat kind of care provider does the client prefer?MaleFemaleNo PreferenceAre there any household pets?YesNo Behavioural BackgroundWhat behaviours are commonly display?What are some of the client's triggers?(ie. loud noise, sleeping issues, new people, large crowds, hot/cold, etc.)What are some behavioural de-escalation management techniques that work for the client?(ie. time alone, music, activity, medication, etc.)Does the client have a friend group?YesNoCan the client be left alone?YesNoDoes the child/youth have a history of being Absent from Care without informing staff? (Running away)YesNoDietary and Meal InformationDoes the client have any special dietary issues? If yes, please specify:What times are the client meals?Sleep InformationWhat are the clients regular sleep and wake times? Nap times?Are there any sleep issues? If yes, please specify:Does the client have a sleep routine?(i.e. specific blankets, pillows, etc.) Activity Information & PreferencesWhat are the client's home activities?Does the client require supervision of certain activities?(i.e. supervised computer time, etc.)Scheduling RequirementsWhat is the proposed care schedule for the client?Please be as detailed as possible (i.e. times of the day, days of the week, number of hours/shifts per month, etc.)Relevant DocumentsAny relevant medical documents, reports, current court ordered documents, custody orders, etc. Drop files here or
