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Starting the Home Care Conversation
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Ask the Expert
FAQs
FHC Videos
About
About Freedom
Why Freedom?
Service Areas
Mankato Office
Minneapolis Office
Owatonna Office
Care Stories
Team
News & Press
Careers
Contact Us
Services
Home Care
24 Hour Live-in Care
Case Management
VA Community Care
Health Care Services
Hospice Care
Dementia Care
Freedom Programs
FAQs
Family
Care While You’re Away
Respite
Care Stories
Family Room Portal
FAQs
Clients
In-Home Assessment
Providers You Can Trust
Planning and Financing Your Care
Fall Prevention
Care Stories
FAQs
Professionals
When to Refer
Intake Form
Home Care vs. Home Health
Reducing Readmissions
Freedom Programs
Resources
Starting the Home Care Conversation
Local Resources
National Resources
Family Room Portal
Service Areas
Ask the Expert
FAQs
FHC Videos
Intake Form
Please fill out the intake form below download the form
here
.
Intake Form
Client Information
First Name
*
Last Name
*
Phone Number
*
Date of Birth
*
Address
*
Address
Address
Address
City
City
State
State
Zip Code
Zip Code
Diagnosis
*
Anticipated Discharge Date
Discharge Instructions
Current Care Setting
Primary Doctor
*
Location
*
Emergency Contact
*
Emergency Contact Phone Number
*
Relationship
*
Care Conference Date
*
Care Conference Location
*
Date set for Freedom Home Care Appointment
*
Freedom Home Care Appointment Location
*
Referral Information
Contact
Title
Referral Contact Phone Number
Follow-Up Requested
Services Needed
Companion
Support, friendship, socialization
Overall monitoring of well-being
Encourage/assist in participation with social activities
Assist with correspondence with family and friends
Alzheimer’s care
Respite care for family members
Hospital sitting
Other
Other
Medical
Medication management services
Hands-on assistance with transfers and mobility
Delegated nursing tasks to caregivers
Other
Other
Personal Assistance
Bathing, toileting, personal hygiene assistance
Grooming and dressing supervision
Ambulation assistance/fall prevention
Medication reminders
Meal planning/preparation
Laundry/bed linens
Light housekeeping
Assistance with pet care
Shopping/errands
Transportation to appointments, etc.
Other
Other
Case Management
Identifying/coordinating resources & services
Coordinating/attending appointments
Hospital visits/discharge planning
Relocation assistance
24/7 emergency availability
Crisis intervention
Assessments/consultations
Advocacy/education
Assist with health care advanced directives
Provide case management reports
Other
Other
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