Get Marc Client Intake Form 2011-2025

The MARC Client Intake Form is essential for those seeking in-home services. This guide provides clear, step-by-step instructions on how to complete the form online to ensure all necessary information is accurately submitted.

Follow the steps to complete the MARC Client Intake Form online:

1. Press the ‘Get Form’ button to access the MARC Client Intake Form and open it in your online editor.
2. Begin by entering client information in the designated fields. Provide the client's last name, first name, middle initial, gender, birth date, Social Security number, and Department of Community and Nutrition identification number.
3. Fill out the address section, including street address, city, zip code, and county. Ensure that the phone number provided is correct.
4. Specify marital status and legal status. Indicate whether the client is responsible for themselves.
5. Select the primary language used by the client.
6. For power of attorney, list the name and phone number of the designated individual. Provide details about guardianship if applicable.
7. Indicate the client's age and veteran status, including ethnicity and race as necessary. Complete income information accordingly.
8. Fill out the primary emergency contact section with their name, relationship, and contact information. Repeat this for the second emergency contact.
9. Provide the MARC service area and specify the services requested. Fill out the service provider information.
10. Assess the client's nutritional status, checking each relevant item and calculating the total score to determine the risk level.
11. Complete the functional assessment by checking the appropriate boxes for each activity of daily living, indicating the type and frequency of assistance needed.
12. Evaluate household conveniences to identify any health and safety concerns within the client's home.
13. Address questions regarding the client's place of residence, mobility challenges, and overall safety.
14. Complete the fall risk screening by discussing the client’s history of falls and related concerns.
15. Detail any medical conditions using the provided code system. Include current medical providers and contact details.
16. Answer the health care utilization questions to review the client's medical history and satisfaction with care.
17. Lastly, review all submitted information for accuracy. Save changes, download, print, or share the completed form as needed.

Start completing the MARC Client Intake Form online now to ensure you provide all necessary information promptly.