Get Dementia Support Services Program Consumer Intake Form - Alz

This guide provides clear instructions for completing the Dementia Support Services Program Consumer Intake Form online, ensuring you provide all necessary information for effective support. Completing this form accurately is crucial for accessing the appropriate services for individuals living with dementia.

Follow the steps to effectively fill out the form online.

1. Press the ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. Begin filling out the Consumer Information section. Input the consumer's first name, middle initial, and last name. Provide the full address, including city, state, and zip code. Enter the phone number in the designated format.
3. Move on to the MSC Information section. Here, you'll need to fill in the MSC’s first name, last name, agency affiliation, and contact details including address, phone number, and email.
4. Next, provide information about the family, legal representative, or advocate responsible for the consumer's care. Include their first name, last name, relationship to the consumer, and complete contact information.
5. Fill out the Residential Information section, providing the residential manager's name, agency affiliation, and contact information. Additionally, indicate the type of residence from the specified options and the number of individuals residing in the household.
6. Proceed to the Day Services Information, where you will choose the program type that fits the consumer’s needs. Also, identify the primary contact for day services and supply their complete information.
7. In the Information About Consumer section, provide responses to questions regarding the consumer's gender, marital status, date of birth, race/ethnicity, fluent languages, and medical details including physician contact, social security, and insurance information.
8. Answer whether the consumer has been diagnosed with Alzheimer’s disease or other dementia. If applicable, note the current diagnosis and the frequency of assistance needed for various activities.
9. Finally, indicate how often the caregiver has observed specific behaviors in the consumer by checking the appropriate boxes next to each provided behavior.
10. Review all entries for accuracy and completeness. After confirming all information is correct, save any changes made to the document. You may then choose to download, print, or share the form as needed.

Complete your documents online to ensure a smooth intake process.