Skip to Content
Initial Intake Form

Discovery Call & Initial Intake

Use this form to capture the first conversation in a clear, typed format. Share what is known now; every detail can be updated as support needs become clearer.

Jump to a section

This form can be completed during a phone call or shared with a family before the first conversation. It is intentionally practical, non-clinical, and focused on support, comfort, routines, and next steps.

Typed + searchable
1

Family contact information

Start with the best person for follow-up.

Back to top
2

Person receiving support

Basic context about the person we may support.

Back to top
3

Reason for reaching out

What changed, what is getting harder, or what the family is planning for.

Back to top
4

Support that may be helpful

Choose what fits now. This can change later.

Back to top
What kind of support would be helpful? Select all that apply. It is okay to choose "not sure yet."
5

Home, safety, and comfort notes

Anything that helps us be thoughtful before coming into the home.

Back to top
Important: Colorado Homestead Care provides non-medical support. If someone is in immediate danger or needs urgent medical help, call 911 or the appropriate emergency service.
6

Preferences, routines, and meaningful activities

Small details help support feel personal and respectful.

Back to top
7

Transportation and community outings

Capture the general need now. Formal authorization can come later.

Back to top
8

Family involvement and next steps

End with who should be included and what should happen next.

Back to top

Submitting this form saves the typed intake details to the family record so the conversation can be reviewed without handwritten notes.

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