Military Intake Form

New Client Details
Client Name*
First Last
Gender*
Date 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 Postal Code

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Guardian & Contact Details
Guardian Name
First Last
Main Phone Number
Secondary Phone Number
Email
Relationship
- Add an additional Parent/Guardian?
Additional Guardian Details
Guardian Name
First Last
Main Phone Number
Secondary Phone Number
Email
Relationship
Secondary Contact Phone Number
Relationship

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Emergency Contact Details

Additional Emergency Contact Details

First Name	Last Name	Relationship	Primary Phone Number	Secondary Phone Number	Email Address

Please have 2 emergency contacts listed (In addition to guardian details)

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Medical Information & Care Goals
Official 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)?
File
Does the client need medication reminders?
If so, please list times and frequency.

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Activities of Daily Living (ADLs)
Does the client require assistance with toileting?
- Yes
- No
Does the client require assistance with eating?
- Yes
- No
Does the client require assistance with ambulation?
- Yes
- No
Does the client use a mobility aid?
- Yes
- No
Is the client a fall risk?
- Yes
- No
Does the client require transfer assistance?
- Yes
- No
Are there any transfer aids in use?
(i.e. gait belt, hoyer lift, etc.)
- Yes
- No
Does the client require assistance with bathing/showering?
- Yes
- No
Does the client require assistance with grooming/dressing?
- Yes
- No
Does the client require assistance with sleeping?
- Yes
- No
Instrumental Activities of Daily Living (IADLs)
Does the client require assistance with meal preparation?
- Yes
- No
Does the client require assistance with medication administration?
- Yes
- No
What kind of care provider does the client prefer?
- Male
- Female
- No Preference
Are there any household pets?
- Yes
- No

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Behavioural Background
What 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?
- Yes
- No
Can the client be left alone?
- Yes
- No
Does the child/youth have a history of being Absent from Care without informing staff? (Running away)
- Yes
- No
Dietary and Meal Information
Does the client have any special dietary issues? If yes, please specify:
What times are the client meals?
Sleep Information
What 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.)

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Activity Information & Preferences
What are the client's home activities?
Does the client require supervision of certain activities?
(i.e. supervised computer time, etc.)
Scheduling Requirements
What 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 Documents
Any relevant medical documents, reports, current court ordered documents, custody orders, etc.
Drop files here or

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Land Acknowledgement for Treaty 6

CarePros respectfully acknowledges that we are located on Treaty 6 territory, a traditional meeting grounds, gathering place, and travelling route for diverse Indigenous peoples including the Cree, Blackfoot, Metis, Nakota Sioux, Iroquois, Dene, Ojibway/ Saulteaux/Anishinaabe, Inuit, and many others whose histories, languages, and cultures continue to influence our vibrant community.

We acknowledge all the First Nation, Metris and Inuit whose footsteps have marked these lands for generations. We are grateful for the traditional Knowledge Keepers and Elders who are still with us today and those who have gone before us. We recognize the land as an act of reconciliation and gratitude to those whose territory we reside on or are visiting.

All of us who live and work here benefit from the signing of this Treaty and have a responsibility to ensure that the spirit of Treaty 6 is honoured and respected.

CarePros respectfully acknowledges that we are located on Treaty 6 territory, a traditional meeting grounds, gathering place, and travelling route for diverse Indigenous peoples including the Cree, Blackfoot, Métis, Nakota Sioux, Iroquois, Dené, Ojibway/ Saulteaux/Anishinaabe, Inuit, and many others whose histories, languages, and cultures continue to influence our vibrant community.

We acknowledge all the First Nation, Métis and Inuit whose footsteps have marked these lands for generations. We are grateful for the Traditional Knowledge Keepers and Elders who are still with us today and those who have gone before us. We recognize the land as an act of reconciliation and gratitude to those whose territory we reside on or are visiting.

All of us who live and work here benefit from the signing of this Treaty and have a responsibility to ensure that the spirit of Treaty 6 is honoured and respected.