Pages 1–4 are your free assessment — submit to start the conversation. Once our team connects with you, we'll send a personalized link to complete your full clinical intake and enrollment before care begins.
AssessmentIntake
Welcome back. One thing first.
Before we proceed with your full intake, please review and sign the privacy and HIPAA Release of Information below. This authorizes us to coordinate your loved one's care with the people you trust.
Your previously submitted information is already saved and will populate automatically. You can also update or expand on what you shared earlier. Read our full privacy policy.
PR
HIPAA Release of Information (ROI)
Authorization to Share Information
I authorize Godwins Family Care LLC to share relevant health and care information with the family members, emergency contacts, and medical providers listed in this intake form for the purpose of coordinating care and ensuring client safety.
This authorization may be revoked in writing at any time and does not extend to any parties not listed in this document.
List names and relationships of anyone we are authorized to speak with beyond the primary contact.
Client or Authorized Representative Signature, HIPAA ROI
Your information is confidential.
Anything you share is used only to match your loved one with the right care team. We never sell or disclose your information without your written consent. A formal HIPAA Release of Information will be reviewed and signed before any care begins. Read our full privacy policy.
01
Client Demographics
02
About You (Form Submitter)
Who is filling out this form today? This is who will receive a copy of the assessment and any follow-up from our team.
03
Primary Family Contact
Your information is confidential.
Anything you share is used only to match your loved one with the right care team. We never sell or disclose your information without your written consent. Read our full privacy policy.
05
Care Situation
Select the option that best describes what you need. We offer both and can help you figure it out.
Home Care Needs
Check all that apply.
In-Home Primary Care Needs
Check all that apply. This is a general snapshot — full detail comes later.
About the Client
A recent fall, hospital stay, caregiver burnout, planning ahead. Whatever’s on your mind.
06
Schedule & Service Level
07
Payment Expectation
A best guess is fine. We’ll work through specifics together.
08
Support Services of Interest
Beyond hands-on caregiving and primary care, which add-on services would be helpful? No commitment.
09
How You’re Doing
There’s no wrong answer. This helps us understand how urgently you need support.
Section Locked
Complete your free assessment to unlock this section. Once our team connects with you, we'll send a personalized link.
08
Homebound Status
"Homebound" generally means leaving home requires considerable effort or assistance.
09
Recent Medical Activity
Check all that apply.
10
Medical Team
11
Home-Based Primary Care Interest
Which in-home medical services would interest the client and family?
Section Locked
Complete your free assessment to unlock this section. Once our team connects with you, we'll send a personalized link.
12
Medical History & Diagnoses
List conditions that affect daily life or care needs.
13
Current Medications
List all current medications. Caregivers provide reminders only — not administration.
14
Skilled Care Needs
Does the client currently require or receive any of these? Check all that apply.
15
Recent Clinical Events
Check all that apply in the past 30-90 days.
Section Locked
Complete your free assessment to unlock this section. Once our team connects with you, we'll send a personalized link.
16
Activities of Daily Living (ADL)
For each area, indicate the level of assistance needed.
17
Instrumental ADLs & Home Support
18
Behavioral & Cognitive Status
19
Six-Month Functional Risk
In the past 6 months, has the client experienced any of these? Check all that apply.
20
Home Environment & Staff Safety
These help us plan staffing safely. Check all that apply.
21
Decision-Making & Legal Status
Check all that apply. We'll request documentation later.
Section Locked
Complete your free assessment to unlock this section. Once our team connects with you, we'll send a personalized link.
22
Emergency Contact 1
23
Emergency Contact 2
24
Caregiver Matching Preferences
Section Locked
Complete your free assessment to unlock this section. Once our team connects with you, we'll send a personalized link.
25
Date of Birth & Identification
Optional. Used only for insurance verification.
26
Insurance Coverage Detail
Check all that apply, then fill in the detail fields below for each active coverage. We'll collect card images separately during enrollment.
Medicare
Medicaid
Commercial Insurance
27
Payment Method
28
Long-Term Care Insurance
Section Locked
Complete your free assessment to unlock this section. Once our team connects with you, we'll send a personalized link.
29
Service Agreement Acknowledgment
Scope of Services
Godwins Family Care LLC provides non-medical personal care services only. Our caregivers are trained to observe and report health changes to the family and medical team but do not provide skilled nursing, medication administration, clinical assessments, or therapeutic services.
Care plans are developed in collaboration with the family and reviewed periodically. Changes to the client's condition or care needs should be reported to Godwins Family Care promptly so that the care plan can be updated accordingly.
Client or Authorized Representative Signature, Service Agreement
30
Emergency & Crisis Protocol Authorization
In the event of a medical or behavioral emergency, Godwins Family Care caregivers are authorized to call 911 or 988 (Suicide & Crisis Lifeline) as appropriate, and will immediately notify the primary family contact. Caregivers will follow established safety protocols and document all incidents.
Client or Authorized Representative Signature, Crisis Protocol
Submitted
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