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CareKit Forms
Community Support Screening Form
Member Details
First Name
Last Name
Date of Birth
Phone Number
SSN
Street Address
Street Address Line 2
City
State
Zip Code
Emergency Contact Name
Emergency Contact #
Emergency Contact Email
Relationship to Member
Medi-Cal ID #
Insurance Plan
Sex
Male
Female
Referral From
Referral Date
Point of Contact Name
Point of Contact Phone Number
Screening Questions
Point Of Contact Title
Income Amount
Income Type
How/ Who is funding the member's stay? (Specifically for ALF Members)
Preferred Location
Diagnosis: (ICD-10 if applicable)
Can Communicate
Yes
No
Has G Tube Catheter Trachs
Yes
No
Has Bed Sores Ulcers Wounds
Yes
No
Uses Wheelchair Walker Cane Oxygen
Yes
No
Needs Hoyer Lift
Yes
No
Has Upcoming Surgeries
Yes
No
Is Ambulatory
Yes
No
Has Drug Substance Use
Yes
No
Has Behavioral Issues
Yes
No
Has Psychiatric Diagnosis
Yes
No
Homeless Status
Last Admission Date from SNF/ Hospital
Name of Intake Team Member
Intake Team Member Email
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