Military Intake Form Step 1 of 9 11% Care TypeEmergency Child CareDeployment RespiteClient Type New (Intake Form Needed) Existing (New Scheduling Request) Existing Client - New Scheduling RequestClient Name First Last Desired Date MM slash DD slash YYYY Notes New Client DetailsClient Name* First Last Gender*MaleFemaleOtherDate of Birth* 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 Relationship Secondary 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)? FileMax. file size: 2 GB.Does the client need medication reminders?If so, please list times and frequency. 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 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? 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 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 Select files Max. file size: 2 GB.
