SOP: Customer Intake Questions | Clarke Domiciliary C

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Customer Intake Questions

Please take a moment to fill out the form.

General Information

First Name

Last name

Phone

Preferred Contact Method (Phone/Email):

Phone

Service Location

Address of the Client/Patient:

City

Region/State/Province

Postal / Zip code

Is the service location different from the client’s address? (Yes/No):

Care Recipient Information

Who is the primary care recipient? (Self/Family Member/Other)

Care Recipient’s Name

Age of Care Recipient

Gender

Relationship to Care Recipient (if not self)

Service Needs

Which services are you interested in? (Select all that apply)

Exercise Therapy as per PT/OT

Activation Gerontology

Nurse

PSW (Personal Support Worker)

Palliative Care

Meals and Meals Delivery

Companionship

Hairdresser/Barber

Skin Care

Nail Care

Transportation

HandyMan Services

Cleaners

Dog Walking

Pet Sitting

Do you have any specific needs or preferences regarding the services selected?

Health & Care Needs

Does the care recipient have any existing medical conditions? (Yes/No)

If yes, please specify the conditions (e.g., Alzheimer’s, dementia, mobility issues)

Does the care recipient require assistance with activities of daily living (bathing, dressing, eating, etc.)? (Yes/No)

Are there any special needs (e.g., 24/7 care, specialized care, dietary restrictions)?

Care Schedule Preferences

What type of care is needed? (Hourly, Daily, Overnight, Live-in, As-needed basis):

Preferred start date for services:

What days of the week are care services needed? (Monday-Sunday):

Preferred service hours (Morning, Afternoon, Evening, Overnight):

Caregiver Preferences

Do you have any preferences for the caregiver’s gender? (Male/Female/No Preference):

Are there any language, cultural, or personality preferences for the caregiver?

Budget & Payment

Do you have an estimated budget for care? (Yes/No)

Are you planning to use insurance, private pay, or a combination of both for services?

If insurance, please specify the provider:

Additional Information

Would you like to schedule a free consultation? (Yes/No):

Thanks for submitting!

Clarke Domiciliary Care

301-56 Sidney Belsey Cres

Toronto, Ontario Canada M6M 5J2

+1 (416) 826-6994

info@clarkedomiciliarycare.ca

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