Client Intake Form: Transitional Bed Program

Referral source

Client details

Client's legal first name

Client's legal last name

Current location

Unit

Room

Date of birth

Health card number

Version code

Address

Apartment, Suite, etc.

City

Province

Postal code

Phone

Emergency contact

Emergency contact first name

Emergency contact last name

Emergency contact primary phone

Is this person a:

POA (power of attorney)

SDM (substitute decision maker)

Relationship to client

Spouse/partner

Child

Sibling

Other

Referral details

Reason for referral

Expected length of time of stay in Transitional Bed Program

Infectious precautions

YesNo

Behavioural concerns

YesNo

Falls risk

YesNo

Mobility aids

Wheelchair

Walker

Cane

Other

Level of mobility support required

Independent

1 Person assist

2 Person assist

Lift

Community supports in place?

YesNo