Holland Connections Intake Form

ADULT INTAKE PACKET CONTACT INFORMATION

Name of Person Completing this Form: Click here to enter text.

Relationship to Client: Click here to enter text.

Today’s Date: Click here to enter a date.

How did you hear about Holland Connections? Click here to enter text.

Daytime Phone: Enter Cell Phone: Enter E-mail Address(s): Click here to enter text.

CLIENT INFORMATION

Client’s Name (Last, First, Middle Initial): Last Name First Name Middle Initial

Gender: Select Date of Birth: Month Day Type Year Age: Type Age

Height: Feet ’ Inches” Weight: Enter Lbs.

Relationship Status: ☐ Married ☐ Single ☐ Separated ☐ Divorced ☐ Widowed

Occupation: Click here to enter text. Total Years of Education: Enter Highest Educational Degree: Enter

The questions listed below are voluntary. Information is requested for demographic/record keeping purposes only.

Client’s ethnicity/race (check only one):☐ American Indian or Alaska Native ☐ Native Hawaiian or Pacific Islander☐ Asian ☐ Hispanic or Latino☐ Black or African American ☐ White or Caucasian

Primary language spoken at home: Click here to enter text.Secondary language spoken at home (if applicable): Click here to enter text.

Daytime Phone: Enter Cell Phone: Enter E-mail Address(s): Click here to enter text.

REFERRAL INFORMATION

Primary Physician: Click here to enter text. Phone: Enter

Primary Physician Address: Click here to enter text.

Referring Physician: Click here to enter text. Phone: Enter

Referring Physician Address: Click here to enter text.

Anticipated Source(s) of Funding: ☐ MA ☐ Private Pay ☐ Insurance

Primary Insurance:

Policy Holder: Click here to enter text. DOB: Enter Place of Employment: Click here to enter text.Page 1 of 10

Holland Connections Intake Form

Insurance Carrier: Click here to enter text.

Group #: Enter ID#: Enter Policy #: Enter

Secondary Insurance (if applicable):

Policy Holder: Click here to enter text. DOB: Enter Place of Employment: Click here to enter text.

Insurance Carrier: Click here to enter text.

Group #: Click here to enter text. ID#: Enter Policy #: Enter

Medical Assistance/TEFRA (if applicable):

Policy Holder: Click here to enter text. DOB: Enter Place of Employment: Click here to enter text.

Group #: Enter ID#: Enter Policy #: Enter

***Please include a copy of all insurance cards (front and back) listed above.***

FAMILY MEDICAL AND PSYCHOLOGICAL HISTORY

Please indicate all medical conditions that the client has been diagnosed with:

☐ Anxiety ☐ Congenital Disorder (please

describe): Enter

☐ Psychiatric Hospitalization

☐ Alcohol Dependency ☐ Depression ☐ Schizophrenia

☐ Autism ☐ Speech and Language Disorder

☐ Attention Deficit Disorder ☐ Epilepsy/Seizure Disorder ☐ Stroke

☐ Blindness/Visual Impairment ☐ Hearing loss/Deafness ☐ Thyroid Disease

☐ Bipolar Disorder ☐ Learning Disability ☐ Tourette's or Tic Disorder

☐ Cancer (please describe):

Enter

☐ Mental retardation/Intellectual

Disorder

☐ Chemical Dependency

☐Low Blood Pressure ☐ Muscular Dystrophy ☐ Chronic Illness (i.e. Diabetes,

Lupus, etc.) (please describe):

Enter

☐High Blood Pressure ☐ Obsessive Compulsive Disorder

☐High Blood Pressure ☐ Other: Enter

PHYSICAL HEALTH INFORMATION

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Holland Connections Intake Form

What is the current health status of the client?

☐ Excellent ☐ Good ☐ Fair ☐ Poor ☐ Don’t Know

Other serious injuries/surgeries: Click here to enter text.

Hospitalizations (reason) DatesClick here to enter text. EnterClick here to enter text. EnterClick here to enter text. EnterClick here to enter text. Enter

Does the client take medications on a daily basis? ☐ Yes ☐ No

If yes, please complete the table below and include present and past medications taken for an extended period.

Name of Medication Purpose Dosage Start Date

Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text.

Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text.

Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text.

Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text.

Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text.

Is the client allergic to any medications? ☐ Yes ☐ NoIf yes, please list medications.Click here to enter text.

Please list in detail all known allergies (include food, animal, plants/other): Click here to enter text.

Are the client’s immunizations up-to-date? ☐ Yes ☐ No ☐ Don’t Know

Has the client received genetic testing? ☐ Yes ☐ No

***IF YES, PLEASE INCLUDE A COPY OF GENETIC TESTING REPORTS***

Is the client currently seeing any medical specialists or therapists (i.e., neurology, psychology, etc.)?

☐ Yes ☐ No

If yes, please provide name: Click here to enter text.

LIVING ENVIRONMENT

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Holland Connections Intake Form

Living Environment:

Address: Enter

Client lives with (check all that apply): ☐ Alone ☐ Spouse ☐ Other (specify): Click here to enter text

1. What type of setting does the client currently live in?

☐ House ☐ Apartment ☐ Assisted Living Facility

☐ Skilled Nursing Facility ☐ Group Home ☐ Other (specify): Click here to

enter text

2. Does the setting have multiple levels?

☐ Yes ☐ No

a. If yes, does it have:

☐ Stairs with a railing ☐ Stairs without a railing

☐ Elevator ☐ Ramps

3. Does the bathroom have:

☐ Walk in shower ☐ Bathtub

☐ Bathtub/shower combination ☐ Other (specify): Click here to

enter text

ACTIVITIES OF DAILY LIVING

Please indicate the client’s level of independence within the following activities:

Independent Needs Some Help Dependent on OthersPutting socks on ☐ ☐ ☐Taking socks off ☐ ☐ ☐Putting shoes on ☐ ☐ ☐Taking shoes off ☐ ☐ ☐Putting shirt on ☐ ☐ ☐Taking shirt off ☐ ☐ ☐Putting pants on ☐ ☐ ☐Taking pants off ☐ ☐ ☐Tying shoes ☐ ☐ ☐

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Holland Connections Intake Form

Brushing teeth ☐ ☐ ☐Flossing teeth ☐ ☐ ☐Washing hands ☐ ☐ ☐Bathing/showering ☐ ☐ ☐Money management ☐ ☐ ☐Home management (i.e. laundry, dishes, cleaning, etc.)

☐ ☐ ☐

Meal preparation/cooking ☐ ☐ ☐Driving ☐ ☐ ☐Feeding/using utensils ☐ ☐ ☐Toileting and hygiene routine

☐ ☐ ☐

Fastening buttons ☐ ☐ ☐Fastening zippers ☐ ☐ ☐Fastening snaps ☐ ☐ ☐

1. Does the client use any of the following adaptive equipment to complete activities of daily living?

☐ Sock Aid ☐ Shoe Horn ☐ Tub/Shower Chair

☐ Tub/Shower Transfer Bench ☐ Transfer Board ☐ Bedside Commode

☐ Toilet Riser ☐ Reacher ☐ Grab Bars

☐ Adaptive Utensils ☐ Adaptive Dishes ☐ Other (specify): Describe

2. Does the client experience any of the following difficulties with sleep? (Select all that apply):

☐ Difficulty falling asleep ☐ Waking in the night ☐ Nightmares ☐ Early morning waking

☐ Night terrors ☐ Sleeps too much ☐ Snoring ☐ Apnea

☐ Other: Describe

3. Does the client have any of the following difficulties with elimination?

☐ Daytime wetting ☐ Toilet refusal ☐ Night wetting

☐ Constipation

☐ None

☐ Soiling

☐ Other: Describe

☐ Diarrhea

FEEDING

Please indicate how often the following occur:

Frequently Sometimes NeverPage 5 of 10

Holland Connections Intake Form

Frequent clearing of throat or general feeling of something being stuck

☐ ☐ ☐

Difficulty with chewing or consuming hard textures (i.e. pretzels, carrots, etc.)

☐ ☐ ☐

Difficulty with chewing or consuming chewy textures (i.e. meat, noodles, etc.)

☐ ☐ ☐

Difficulty with consuming foods with two or more textures (yogurt with granola, cereal with milk, etc.)

☐ ☐ ☐

Difficulties drinking from a straw

☐ ☐ ☐

Difficulties drinking from a cup

☐ ☐ ☐

Frequent coughing when consuming foods

☐ ☐ ☐

Frequent coughing when consuming liquids

☐ ☐ ☐

1. Are there any diet restrictions? ☐ Yes ☐ No If yes, please list: Click here to enter text.

2. Does the client have difficulty gaining/maintaining weight? ☐ Yes ☐ No

3. Do you have any other concerns about the client’s current eating habits? Click here to enter text.

4. Has the client received a video swallow study? ☐ Yes ☐ No a. If yes, where? Click here to enter text.

b. If yes, when? Click here to enter text.

***IF YES, PLEASE INCLUDE A COPY OF VIDEO SWALLOW STUDY REPORTS***

MOTOR SKILLS

1. Does the client use the following equipment for mobility?

☐ Cane ☐ Walker

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Holland Connections Intake Form

☐ Wheelchair ☐ Other (specify): Click here to

enter text

Please indicate how often the following occur:

Frequently Sometimes NeverTires easily with physical activity

☐ ☐ ☐

Appear or feel stiff and awkward in movement

☐ ☐ ☐

Feel clumsy or bump into things

☐ ☐ ☐

Have difficulty learning new motor tasks that have several steps

☐ ☐ ☐

Take a long time to do motor tasks

☐ ☐ ☐

Difficulties with handwriting ☐ ☐ ☐Difficulties with keyboarding

☐ ☐ ☐

Difficulties with texting ☐ ☐ ☐Difficulties manipulating objects in hands

☐ ☐ ☐

MOVEMENT AND BALANCE

Please indicate how often the following occur:

Frequently Sometimes NeverFrequent falling ☐ ☐ ☐Get nauseated or vomit from motion (i.e. car rides, airplane rides, spinning)

☐ ☐ ☐

Difficulty ascending or descending stairs

☐ ☐ ☐

Avoid activities that challenge balance (i.e. picking up objects off floor, reaching for objects on high shelves)

☐ ☐ ☐

Have difficulty sitting still (i.e. at meal times or in a meeting)

☐ ☐ ☐

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Holland Connections Intake Form

VISUAL PROCESSING

Please indicate how often the following occur:

Frequently Sometimes NeverDraw numbers or letters backwards

☐ ☐ ☐

Skip letters, words, or lines when reading

☐ ☐ ☐

Have trouble tracking objects with eyes

☐ ☐ ☐

See double ☐ ☐ ☐Close one eye or tilt head while reading

☐ ☐ ☐

Have trouble finding an object in a busy background

☐ ☐ ☐

Become easily distracted by visual stimulation

☐ ☐ ☐

SPEECH

Please indicate how often the following occur:

Frequently Sometimes NeverStuttering ☐ ☐ ☐Drooling when talking/engaging in activities other than eating

☐ ☐ ☐

Difficulty with word finding ☐ ☐ ☐Having to restate due to communication partners not understanding

☐ ☐ ☐

1. How does the client communicate?☐ Vocal Communication ☐ Written Communication

☐ Communication Device ☐ Other: Describe

2. What does the client do when they are not understood?

☐ Repeat ☐ Give up

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Holland Connections Intake Form

☐ Become frustrated ☐ Other: Describe

MEMORY

Please indicate how often the following occur:

Frequently Sometimes NeverGets lost easily in new places

☐ ☐ ☐

Gets lost easily in familiar places

☐ ☐ ☐

Forgets to complete activities of daily living (i.e. cooking a meal, taking medication, etc.)

☐ ☐ ☐

Misses or forgets about appointments

☐ ☐ ☐

Forgets specific words or has to describe words

☐ ☐ ☐

Enters a room and forgets why they went there or what they needed

☐ ☐ ☐

GENERAL EMOTIONAL AND SOCIAL

Please indicate how often the following occur:

Frequently Sometimes NeverHave strong outbursts of anger or emotions

☐ ☐ ☐

Have difficulty calming self when upset

☐ ☐ ☐

Tend to startle easily ☐ ☐ ☐Have difficulty or avoid engaging in group activities

☐ ☐ ☐

Have difficulty or avoid talking to new people

☐ ☐ ☐

Have difficulty navigating different social situations

☐ ☐ ☐

Have difficulty with changes in routines

☐ ☐ ☐

Have difficulty ☐ ☐ ☐Page 9 of 10

Holland Connections Intake Form

making/maintaining friendships

ADDITIONAL QUESTIONS

What is the main reason the client is seeking services: Click here to enter text.

If the client is currently receiving services outside of Holland Connections, please list in the table below:

Service Provider Frequency (i.e., twice a week)General Goals (i.e., increase

vocabulary, increase fine motor skills, increase articulation)

Speech-Language Pathologist Enter Click here to enter text.

Occupational Therapist Enter Click here to enter text.

Physical Therapist Enter Click here to enter text.

Other: Specify Enter Click here to enter text.

Other: Specify Enter Click here to enter text.

***IF THE CLIENT RECEIVES SERVICES, PLEASE INCLUDE THE MOST RECENT EVALUATION AND TREATMENT PLAN WHEN RETURNING THIS PACKET***

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