Intake Specialist: *
Date of interview: *
Elder Name: *
Date of Birth:
Phone (Home):
Phone (Cell):
Email:
Address (Physical and Mailing):
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
Church or religious affiliation, if any?
Does anyone in the household smoke?YesNo
If Yes, Who?
Any pets in the home?YesNo
If yes, please list type, breed, name, and any other important details:
Fit for Life
Meals on Wheels
Lifeline
Office for the Aging
Adult Protective Services (APS)
Alzheimer’s Association
Expanded In-Home Services for the Elderly (EISEP)
Home Energy Assistance Program (HEAP)
Supplemental Nutrition Assistance Program (SNAP)
Other Services:
Describe any physical health issues or concerns:
Cane
Wheelchair
Walker (Able to use independently)
Walker (Needs transfer assistance)
Other mobility barriers (Please list):
Are you currently on oxygen?YesNo
No Large SUVs
No Trucks
No Low Vehicles
Other Vehicle Restrictions?
Have you been diagnosed with any dementia related diseases?YesNo
If yes, please describe:
Are you currently receiving any behavioral health services or supports?YesNo
If yes, please describe (please provide the behavioral health providers information in the contact portion of the intake):
Do you plan to receive annual vaccinations for:COVID-19FluBothNeither
Confirm Medicaid enrollment:Enrolled in MedicaidNot enrolled in Medicaid
At this time, Mercy Care is unable to offer transportation assistance to those who use a wheelchair, cannot use a walker independently (i.e., requires assistance getting up from a seated position and/or sitting down), or are on oxygen. Because Medicaid provides medical transportation, we are unable to provide medical transportation to those enrolled in Medicaid, however, we can assist those enrolled in Medicaid with non-medical transportation.
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 Medical Supervisor Contact for Medical Medicaid Transportation: 315-299-2758.
Name:
Relationship:
Address:
Phone:
Name: *
Practice Address:
Mercy Care Friendship Volunteer preference? Please choose an OptionFemaleMaleNo Preference
When possible, would you prefer to have the same Mercy Care Volunteer?Please choose an OptionYesNoNo Preference
Do you have someone in mind?
Friendly Home Visits
Friendly Phone Calls
Technology Assistance/iPad Program
Outings Together
Errands/Non-Medical Transportation
Medical Transportation
Recreational Activities
Crafts, Gardening, Art, Music
All Friendship Volunteer Services
Health Education
Personal Health Counseling
Spiritual Caregiving
Connecting with Community Resources
Advocacy
All Faith Community / Parish Nurse Services
Spiritual Support - In Person
Spiritual Support - Phone Calls
Connecting with Faith Community
All Spiritual Care Companion Services
Transportation to Medical / Health Appointments
Accompaniment to Appointments
Assistance with scheduling and/or follow-up
Medical / Health Forms
Navigating health and social systems, and portals
Errands (prescriptions, other)
All Health Care Companion Services
Any specific services requested (such as grocery shopping, garden visits, free iPad program, etc.):
If any services were requested but not recommended, please provide a brief explanation:
Photo Consent: Photos and videos may be used, with permission, in Mercy Care newsletters, website, and promotional materials.
Do you consent to photograph / video at Mercy Care events?YesNo
Consent to Services: Do you consent to enroll in Mercy Care’s Services?YesNo
Elder Signature:
I can confirm that the services requested by the Elder are within the scope of the services provided by Mercy Care for the Adirondacks and may be fulfilled by a Mercy Care Volunteer if available.Yes. Any Mercy Care Trained Volunteer.Yes. But only by a Faith Community / Parish Nurse Volunteer.No. I do not recommend a Mercy Care Volunteer be assigned.
If you do not recommend that Mercy Care assign volunteers to this Elder, or only recommend a Faith Community / Parish Nurse be assigned, please explain why:
Other comments or additional notes (please include any health or safety concerns observed in the home):
Additional recommendations (services / resources the Elder may benefit from):
Time:
Miles:
Please initial here to acknowledge that the information provided is accurate to the best of your knowledge:
Please advise the 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. Inform them they can call 518-523-5585 with service requests or questions at any time and can leave a message if needed. Mercy Care’s office hours are Monday – Friday, 8am – 4pm.
