Client Intake Form - JADE Senior Care Services

Your Information (Person Requesting Service)

Your Full Name *

Relationship to Gem *

Your Email *

Your Phone Number *

Gem Information (Person Receiving Care)

Gem's Full Name *

Preferred Name What should we call them?

Date of Birth *

Gem's Phone (if applicable)

Emergency Contact

Same as person requesting service above

Contact Name *

Relationship *

Phone Number *

Backup Contact Phone (optional)

Residence Details

Residence Type *

Facility Name (if applicable)

Address *

Room/Unit Number

Check-in/Check-out Procedures

Mobility & Health Notes

Mobility Level *

Assistive Devices Used

Walker Cane Wheelchair Hearing Aids Glasses Oxygen None

Cognitive Considerations Any memory, comprehension, or cognitive notes that help us communicate effectively.

Allergies List any allergies we should be aware of.

Relevant Health Notes Non-medical notes that affect how we provide accompaniment (we do not provide medical care).

Communication & Comfort Preferences

Preferred Communication Style

Primary Language

Comfort Preferences & Routines What helps your Gem feel comfortable and at ease?

Anxieties or Concerns About Appointments

Appointment Information

Appointment Type *

Provider/Destination Name

Pickup from residence address (same as Gem's residence)

Appointment Address *

Appointment Date *

Appointment Time *

Expected Duration * Include travel time and any waiting periods.

Services Needed

What support do you need? *

Transportation & Accompaniment Presence during appointment Communication support (help relay information) Wheelchair assistance Wait and return transport

Additional Instructions

Preparation Instructions

Follow-up Instructions

Additional Notes

Rates & Billing

Hourly Rate: $45 per hour, per team member
Minimum Visit: 2 hours
Billing: Invoices are issued after service completion
Payment: Due within 14 days of invoice date

Cancellation Policy

24-Hour Notice: Cancellations require 24 hours advance notice
Late Cancellation Fee: Cancellations with less than 24 hours notice may be subject to a 2-hour minimum charge
Emergencies: We understand emergencies happen - please contact us as soon as possible

Scope of Service & Safety

Non-Medical Support: JADE provides companionship and accompaniment services only. We do not provide medical care, administer medications, or make medical decisions.
Safe Transport: We commit to safe transportation on foot or by wheelchair, in compliance with facility procedures.
Communication: With your consent, we will coordinate with family members and facility staff as needed during service.

Acknowledgments *

Please check each box to confirm your understanding:

I understand that JADE provides non-medical accompaniment support only and does not provide medical care, nursing, or medication administration. I agree to the cancellation policy requiring 24 hours advance notice. I consent to JADE communicating with family members and facility staff as needed during service to ensure the Gem's wellbeing. I acknowledge the limitations of non-medical support services and release JADE from liability for medical events beyond their control. I agree to JADE's privacy policy and consent to the collection and use of personal information as required to provide services (in compliance with PIPEDA).

Digital Signature

Type Your Full Legal Name *

Date

How did you hear about us?

I confirm that all information provided is accurate and I agree to the terms of this Service Agreement.

Client Intake & Service Agreement

Contact & Gem Information

Health & Preferences

Appointment & Service Details

Service Agreement & Consent

Rates & Billing

Cancellation Policy

Scope of Service & Safety