Less admin chasing
Families can complete the intake on their own time, with progress saved in the browser as they go.
Agent tool
Senior Assessment Intake Tool
Create a custom intake page that carries the referral contact into the final review and share screen. This gives families a easy guided workflow, reduces back-and-forth, and produces a cleaner summary you can review or forward.
Simple to send Mobile friendly Easy to review
More consistent assessments
The guided steps keep mobility, ADLs, medication, and functional ability ratings structured the same way every time.
Better handoff-ready output
The final review creates a readable summary that is easy to copy, print, save, or share when appropriate.
Example output
✅ Preview Senior Assessment Form
Here is an example of what the final report can look like after the intake is completed.
🔗 Referral
- Referral Contact
- Jane Smith
- Referral Email
- intake@example.com
🪪 Personal Information
- First Name
- Margaret
- Last Name
- Wilson
- Age
- 84
- Gender
- Female
- Contact Information
- Daughter: Lisa Wilson, (555) 222-0148
- Medical Diagnosis
- Dementia with increasing fall risk
- Assessment Date
- Apr 10, 2026
- Assessment Completed By
- Senior Care Advisor
🩺 Health & Daily Living
- Diagnosis
- Needs cueing for routine tasks and close mobility monitoring
- Mobility Level
- Needs Assistance
- Eating
- Needs Supervision
- Dressing
- Needs Assistance
- Bathing
- Needs Assistance
- Toileting
- Needs Supervision
- Continence
- Needs Supervision
💊 Medication & Support
- Medication Self-Management
- Needs Assistance
- Family Support
- Available
- Community Support
- Limited
🏠 Functional Abilities
- Cooking
- Total Assistance
- Housekeeping
- Total Assistance
- Transportation
- Total Assistance
🩹 Additional Health Needs
- Glasses
- Wears
- Dentures
- Does Not Wear
- Oxygen Tank
- Does Not Use
- Catheter
- Does Not Have
- Wounds
- Absent
- Hospice Services
- Not Receiving
📝 Services & Notes
- How They Heard About Us
- Referral
- Other Referral Detail
- Not provided
- Services Interested In
- Assisted Living, Memory Care
- Additional Comments
- Family prefers a calm setting close to daughter.
- Overall Level of Care Required
- Moderate
- Recommendations
- Tour memory care and enhanced assisted living options.