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
Other Interests:
If you work(ed) outside the home, what type of work?
Are you a veteran?Please Choose and OptionYesNo
Does anyone in the household smoke?YesNo
If you have pets, number sequentially with type, breed, name, details:
How do you do your shopping?
How do you do your housekeeping?
Church or religious affiliation, if any?
Would you like a Faith Community Nurse or Spiritual Care Companion to visit you to discuss health care or spiritual care needs?YesNoNot at this time
Who is your primary healthcare provider?
Primary healthcare provider location:
Who is your primary support person?
Name and address:
How is your general health?
Describe any physical disabilities:
Wheelchair
Walker
Cane
Other:
Describe any memory or cognitive concerns:
Describe any mental health concerns:
If applicable, who is your mental health care provider?
Are you enrolled in Medicaid?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)
Who will you accept as a Friendship Volunteer? Please choose an Optionfemalemaleeither
Requested Volunteer:
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
Friendly Visits
Friendly Phone Calls
Technology Assistance/iPad Program
Errands/Non-Medical Transportation
Medical Transportation
Meal Preparation or Light Housekeeping
No Large SUVs
No Trucks
Heath Counseling
Spiritual Support
Does Elder consent to photograph/video record?Please choose an OptionYesNo
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)
Technology assistance/iPad Program
Spiritual Care Companion
Faith Community Nurse
I DO NOT recommend that Mercy Care assign volunteers to this elder or caregiver for the following reason(s):
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.
