Client Intake Form

Lollipop's Companion Care · Please complete all sections

1. Client Details

Full Name

Date of Birth

Preferred Name / Nickname

Address

Telephone

Email Address

2. Emergency Contact

Full Name

Relationship to Client

Telephone

Email Address

3. GP Details

GP Name

Surgery Name

Surgery Telephone

Surgery Address

4. Health & Wellbeing

Relevant medical conditions or diagnoses

Allergies (food, medication, environmental)

Mobility and physical considerations

Communication needs (e.g. hearing, vision, language)

5. Interests & Preferences

Hobbies and interests

Favourite topics of conversation

Things to avoid or be mindful of

6. Services Required

Home Visits

Social Outings

Care Home Visits

Family Support / Respite

Preferred days / times

Frequency of visits

7. Additional Information

By signing below, I confirm that the information provided is accurate to the best of my knowledge, and I consent to Lollipop's Companion Care holding and using this information to provide the agreed services. I have read and understood the Companionship Privacy Notice.

Signature

Date

Printed Name

Relationship to Client (if not client)

Lollipop's Companion Care · [email protected] · 07931 846267