Intake Specialist Interview for: (Elder Name) *
Elder Physical Address:
Is your mailing address different from your physical address?Please Choose an OptionYesNo
If yes, please provide mailing address:
Elder phone:
Date of intake interview: *
Intake Specialist: *
Crafting
Gardening
Art/Music/Literature
History
Light Exercise
Computer Technology
Outings
Knitting
Puzzles/Games
Coloring
Sports
Bird Watching
Reading
TV
News
Additional Information:
If you work(ed) outside the home, what type of work?
Are you a veteran?Please Choose and OptionYesNo
Particular church or denomination affiliation, if any?
Who will you accept as a Friendship Volunteer? Please choose an Optionfemalemaleeither
Requested Volunteer:
How do you do your shopping?
How do you do your housecleaning?
Who is your primary healthcare provider?
Practice Location:
Who is your primary support person?
Name and address:
How is your general health?
Describe any physical disabilities:
Wheelchair
Walker
Cane
Supported Walking Assistance
Other:
Describe any memory or thinking issues:
Describe any psychological or psychiatric problems:
Psychiatric practitioner’s name, if any?
Would you like a Faith Community Nurse to visit you to discuss your health care or spiritual care needs?Please choose an OptionYesNo
Is Elder a Medicaid recipient?Please choose an OptionYesNo
(If Yes, to order, cancel, or inquire about Medicaid transportation services contact Medical Answering Services (MAS) at 888.262.3975 or www.medanswering.com. Franklin and Essex County Medicaid Supervisor Contact for Medical Medicaid Transportation: 315.299.2758)
Does Elder, or others in Elder’s household, smoke?Please choose an OptionYesNo
If Elder has pets, number sequentially with type, breed, name, details:
Does Elder consent to photograph/video record?Please choose an OptionYesNo
Would Elder like to be assigned a specific Friendship Volunteer?Please choose an OptionYesNo
Last Name *
First Name *
Relationship *
Address
Email
Phone
Last Name
First Name
Relationship
I recommend that Mercy Care assign volunteers to this elder or caregiver for the purpose of providing any or all Mercy Care Services: (check all that apply)
All Services
Friendly Visits (in-home)
Errands/Shopping Assistance
Friendly Phone Calls
Medical Transportation Assistance
Non-Medical Transportation Assistance (Medicaid Recipient)
I DO NOT recommend that Mercy Care assign volunteers to this elder or caregiver for the following reason(s):
Friendly Visits
Transportation Assistance
Outings (Social and Community Engagement)
No Large SUVs
No Trucks
Heath Counseling
Spiritual
Comments or Additional Information:
Time:
Miles:
Please advise prospective Elder that the next step in this process is for this Intake Interview to be reviewed by Mercy Care staff and that someone will be in touch with them soon.
