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Keeping Families Together at Home
Client Intake

Tell Us About Your Home, Routines, and Support Needs

This form helps us understand the person receiving support, the home environment, daily routines, family preferences, and the kind of help that may make life at home feel easier.

Heart Note: You do not need to have every answer. Share what you know today, skip what does not apply, and we will talk through the rest together.
Step One

Share the Details

Tell us about the person receiving support, family contacts, routines, and home preferences.

Step Two

We Review with Care

Colorado Homestead Care reviews the intake and follows up if anything needs clarification.

Step Three

Plan the Support

These details help us prepare a thoughtful support plan and make better companion matches.

This is a planning form for non-medical in-home and community support. It helps us prepare for conversations, support planning, scheduling, and companion matching. If something is urgent or medical, please contact the appropriate emergency or medical professional directly.

Your Contact Information

Who should we contact first about scheduling, questions, and next steps?

Person Receiving Support

Basic information about the person we may support.

Family and Emergency Contacts

Please tell us who may be included in planning, schedule changes, or urgent concerns.

Schedule and Timing

This helps us understand when support may be needed and what rhythm may work best.

Support Interests

Choose anything that may be helpful. We can refine the plan together.

What kind of support is being requested? Select all that apply.

Home and Household Notes

Practical details help visits begin smoothly and respectfully.

Comfort and Safety Notes

Share anything that helps us provide careful, respectful, non-medical support.

Scope Reminder: Colorado Homestead Care provides non-medical support. We do not provide emergency care, clinical assessments, medication administration, wound care, or services that should be handled by a licensed medical professional.

Routines and Meaningful Activities

The little details help support feel personal, familiar, and comfortable.

Transportation and Outings

General planning notes only. A separate authorization should be completed before transportation begins.

Planning Notes and Questions

Anything else we should know before building the first support plan?

Submit Client Intake

After you submit this intake, Colorado Homestead Care will review the details and use them to prepare the next conversation and support plan.

Colorado Homestead Care · Keeping Families Together at Home · 719-299-0851 · care@coloradohomesteadcare.com