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 unlock pages 5–7 and complete your full intake 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
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. A formal HIPAA Release of Information will be reviewed and signed before any care begins. Please share as much or as little as you are comfortable with at this stage. The more we know, the better we can match. Read our full privacy policy.
03
Medical History & Diagnoses
List conditions that affect daily life or care needs.
04
Current Medications
List all current medications. Caregivers provide reminders only — not administration.
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. Please share as much or as little as you are comfortable with at this stage. The more we know, the better we can match. Read our full privacy policy.
05
Activities of Daily Living (ADL)
For each area, indicate the level of assistance needed.
06
Instrumental ADLs & Home Support
07
Behavioral & Cognitive Status
08
Schedule & Service Level
09
Caregiver Matching Preferences
10
Emergency Contact 1
11
Emergency Contact 2
12
Medical Team
13
Payment Method
14
Long-Term Care Insurance
15
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
16
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
