Compliance · free template

Home Care Client Intake Form

In-home and elderly care assessment covering mobility, medications and daily schedule.

A ready-to-use healthcare, legal & specialized form for teams with a niche process that generic forms don't cover: 20 questions, 4 pages, 5 conditional rules.

Questions: 20
Pages: 4
Layouts: classic
Conditional rules: 5
Typical time: 10 min

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Live preview and test console

This is the real form. Answer it to test the 4 conditional rules — nothing is sent or stored.

Page 1 of 4 — Client details

Every question on this page is currently visible.

What happens after submit: nothing is stored in this preview. On your own copy, every response triggers an instant email notification and lands in your response dashboard, ready to export or forward.

Happy with it? Take a copy into your workspace — every question, rule and setting comes with it.

Who this template is for

Home Care Client Intake Form is built for teams with a niche process that generic forms don't cover who need to capture reproducible detail on first contact.

Teams with a niche process that generic forms don't cover working in healthcare, legal & specialized.
Teams who need to capture reproducible detail on first contact without writing code or paying for a custom build.
Anyone replacing requests that need three replies before work can start with one structured record per enquiry.
Respondents are the specific group this workflow serves — the form asks them 20 questions across 4 screens.

Why this form is useful

It removes the cost of requests that need three replies before work can start and turns each submission into a record your team can act on immediately.

8 questions are required, so submissions arrive complete instead of needing a follow-up email.
It captures a phone number for urgent follow-up.
It pins the request to a specific date.
It captures a full postal address.
It allows multiple selections without free text.
Conditional logic hides 5 questions until they are relevant — shorter forms convert better than long ones.
Splitting the form across 4 pages keeps each screen short and shows respondents how much is left.
Every response is stored, searchable and exportable, so nothing depends on one person's inbox.

How to use this template

From copy to live form is a few minutes of work, and every step is reversible.

1Press “Use this template” — a fresh copy of Home Care Client Intake Form lands in your workspace, ready to edit.
2Rename or delete any question, and change what is required. Nothing here is fixed.
3Open Notifications and add the email addresses that should be alerted on each submission; add an auto-reply to the respondent if the form collects an email address.
4Publish it, then either share the link directly or paste the embed snippet into your site — the embedded form resizes to fit and loads no marketing or advertising trackers.
5Watch responses land in Submissions, where you can filter, label and export them to CSV or PDF.

Logic and conditions blueprint

Exactly how this form behaves as it is answered — 5 conditional rules ship with it.

Features advanced show logic: if “Mobility level” is Wheelchair-dependent or Bedbound, the form dynamically exposes “Equipment currently used (hoist, wheelchair, hospital bed, etc.)”. Otherwise that question never appears.
Features advanced show logic: if “Mobility level” is Wheelchair-dependent or Bedbound, the form dynamically exposes “Does the client need assistance transferring in and out of bed?”. Otherwise that question never appears.
Features advanced show logic: if “Medication management” is Needs reminders or Needs full administration support, the form dynamically exposes “Current medication list”. Otherwise that question never appears.
Features advanced show logic: if “Medication management” is Needs reminders or Needs full administration support, the form dynamically exposes “Pharmacy name and phone number”. Otherwise that question never appears.
Features conditional validation: if “Does the client live alone?” is Yes, “Emergency contact (not living with client)” becomes mandatory before the form can be sent.
All 5 rules are editable in the Logic tab, and the built-in checker warns about rules that contradict each other.

About this template

Matching a home care client to the right caregiver and equipment depends on details that are easy to miss in a phone call but simple to capture in a structured form. This intake starts with the client and primary contact's details, then moves into a mobility assessment — the level selected (independent, uses a cane or walker, wheelchair-dependent, or bedbound) determines which equipment and transfer-assistance fields appear next, so an independent client isn't asked about hoist requirements they don't need. A medication management question separates clients who manage their own medication from those who need reminders or full administration support; choosing the latter opens fields for the current medication list and pharmacy contact, which the caregiver will need on day one. A weekly schedule grid captures which days and times care is needed, since staffing depends on this far more than on the general service type. Next-of-kin and emergency contact fields are conditionally required depending on whether the client lives alone — a client living with a spouse or family member can list them as the primary contact, while someone living alone must provide a separate emergency contact before the assessment can be submitted. This form supports care planning; it isn't a substitute for a clinical assessment by a nurse or physician.

What this form asks

Every question is editable — rename it, make it optional, or delete it entirely.

Page 1 — Client details

Client full namerequired
Date of birthrequired
Home address
Client phone number
Does the client live alone?required
Primary contact / family memberrequired
Primary contact phone

Page 2 — Mobility & equipment

Mobility levelrequired
Equipment currently used (hoist, wheelchair, hospital bed, etc.)
Does the client need assistance transferring in and out of bed?
Areas where support is needed

Page 3 — Medication & health

Medication managementrequired
Current medication list
Pharmacy name and phone number
Relevant health conditions
Known allergies

Page 4 — Schedule & emergency contact

Days care is neededrequired
Preferred visit times
Emergency contact (not living with client)required
Emergency contact phone

20 questions in total.

How the form changes as it's filled in

This template ships with 5 conditional rules, grouped into 3 behaviours driven by 3 questions. Everything below is already set up — edit or delete any rule once the template is in your workspace.

Driven by “Mobility level”

Reveals questions
If “Mobility level” is Wheelchair-dependent or Bedbound, the form reveals “Equipment currently used (hoist, wheelchair, hospital bed, etc.)” and “Does the client need assistance transferring in and out of bed?”.

Driven by “Medication management”

Reveals questions
If “Medication management” is Needs reminders or Needs full administration support, the form reveals “Current medication list” and “Pharmacy name and phone number”.

Driven by “Does the client live alone?”

Makes answers required
If “Does the client live alone?” is Yes, “Emergency contact (not living with client)” becomes required before the form can be submitted.

Set it up step by step

1
Match caregiver skills to mobility level
Assign two-person transfer teams only where the form indicates that need, rather than guessing on the day.
2
Confirm the medication list with the pharmacy
Call the listed pharmacy to verify the current medication list before the first visit if administration support is required.
3
Build the roster from the schedule grid
Use the days-and-times answers directly for staffing rather than re-asking the family by phone.
4
Re-check mobility level periodically
Mobility often changes over time — reissue this section every few months rather than relying solely on the original intake.

Mistakes to avoid

Assigning a single caregiver to a client who needs two-person transfers because the mobility section was skipped.
Not requiring a separate emergency contact for clients who live alone.
Leaving the medication list blank for a client who needs full administration support, putting the first visit at risk.

What it pairs with

Most teams don't run this form on its own. These are the forms and systems it sits next to.

What to do with the responses

Match the client to a caregiver based on mobility and medication needs, confirm the schedule with the family, and verify medication details with the pharmacy before the first visit.

Works in this layout

Browse classic templates

Forms that overlap this one

These pages cover the same subject ground as the home care client intake form, matched on the words people actually search for.

Privacy & compliance

This form collects health information. Keep access limited to the people who need it, turn on encrypted answers for the clinical questions, and set a retention window so records don't sit in the dashboard forever.

Frequently asked questions

Is this a clinical assessment?

No — it's an intake and care-planning tool. A clinical assessment by a nurse or physician should happen separately where required.

Can a family member fill this out on the client's behalf?

Yes, that's common — just make sure the primary contact field reflects who actually completed the form.

How often should this be updated?

Most agencies review mobility and medication sections every few months, or immediately after a hospital stay or fall.

What if the client's needs change mid-week?

Use this form for the initial care plan; day-to-day changes are best logged in your caregiver's visit notes rather than resubmitting the whole intake.

Is the Home Care Client Intake Form template free to use?

Yes. You can preview and test Home Care Client Intake Form on this page without an account, and take a copy into your own HelloForms workspace on the free plan. There is nothing to install and no card required to publish it.

What does the Home Care Client Intake Form template ask for?

It asks 20 questions across 4 pages, 8 of which are required. Every question is listed in full further down this page, and each one can be renamed, reordered, made optional or deleted after you copy the template.

Can I edit the Home Care Client Intake Form form after copying it?

Yes — the copy is entirely yours. Change wording, add or remove questions, switch between the classic layout, restyle it to match your brand, and set who gets notified on each submission.

How does the conditional logic in this healthcare, legal & specialized form work?

5 conditional rules ship with the template: Features advanced show logic: if “Mobility level” is Wheelchair-dependent or Bedbound, the form dynamically exposes “Equipment currently used (hoist, wheelchair, hospital bed, etc.)”. Otherwise that question never appears. Features advanced show logic: if “Mobility level” is Wheelchair-dependent or Bedbound, the form dynamically exposes “Does the client need assistance transferring in and out of bed?”. Otherwise that question never appears. Features advanced show logic: if “Medication management” is Needs reminders or Needs full administration support, the form dynamically exposes “Current medication list”. Otherwise that question never appears. All rules are editable in the Logic tab.

Where do responses to the Home Care Client Intake Form form go?

Submissions land in your workspace under Submissions, where you can search, filter, label and export them to CSV or PDF. You can also email a notification to your team on every submission and send the respondent an auto-reply.

Can I embed the Home Care Client Intake Form form on my own website?

Yes. Publish the form and paste the embed snippet into any page or share the direct link. The embedded form resizes to fit its container and loads no advertising or marketing trackers inside the iframe.

More forms teams pair with the home care client intake form.

Related categories

All Healthcare, Legal & Specialized templates