Get Started - Pediatric Intake Form | JC Caring Home Services

1 Child's Info

2 Family Info

3 Medical Info

4 Care Needs

Child's Information

Please provide information about the child who will receive care.

Today's Date

Child's Full Name

Date of Birth

Gender

Address

Medicaid Number

Does your child have private insurance?

Yes No

Does your child receive GAPP services today?

Yes No

Does your child receive any other services from a Medicaid program?

Yes No

Does your child attend school?

Yes No

What is the name of the school?

Select all days your child attends school

Monday Tuesday Wednesday Thursday Friday

What hours does your child attend school each day?

Does your child have a current IEP?

Yes No

Parent/Family Information

Please provide contact information for the child's parents or guardians.

Mother's Information

Mother's Full Name

Mother's Phone Number

Mother's Email Address

Father's Information

Father's Full Name

Father's Phone Number

Father's Email Address

Additional Household Information

Are there any other medically fragile children in the home?

Yes No

Is there anyone else in your home who is currently in the GAPP program?

Yes No

Child's Medical Information

Please provide details about your child's medical conditions and care needs.

What is the child's medical diagnosis?

Does your child have any of the following equipment? (Select all that apply)

Wheelchair Gait Trainer Trach Catheter Shower Chair Walker G-Tube Standers Suction Leg Brace AAC Device Special Bed/Safe Bed Glasses Oxygen Other

Please list other equipment:

Can your child use the bathroom without assistance?

Yes No

Does your child receive any of the following services? (Select all that apply)

OT (Occupational Therapy) PT (Physical Therapy) Speech Therapy My child does not receive any of these services

Pediatrician Contact Details

Name of Practice

Doctor's Name

Address

Phone Number

Additional Medical History

Does your child have seizures?

Yes No

List all surgeries and hospitalizations with dates

Last appointment date with primary care physician

Does your child have any allergies?

Yes No

Describe your child's limitations in your words

How Can We Help You?

Listed below are tasks that our staff can assist you with when providing care for your child. Please select all that apply in each category.

Bathing

Bed Bath Shower Bathtub Bathing

Ambulation

Ambulation Assistance Monitor for Fall Prevention Range of Motion Exercise

Companionship (Select all that apply)

Assist with Hobbies Encourage Conversation Caregiver Relief Companion Sitter Laundry Assistance Reading Walk Outside Watch TV

Housekeeping (Select all that apply)

Change Linen Dishes Laundry Clean Bathroom Bedroom Den Kitchen Cut Food Dusting Empty Dishwasher Light Housekeeping Make/Change Bed Mop Floor Sweep Floor

Transferring (Select all that apply)

Hands On Assist Standby Assist Verbal Cue/Reminder

Diet (Select all that apply)

Regular Pureed Liquid Soft

Personal Care (Select all that apply)

Assist with Medical Device Brush Hair Nail Care Brush Teeth Rotate/Reposition Comb Hair Shampoo Grooming Eating Toileting Assistance Escort to Activities Apply Lotion

Toileting (Select all that apply)

Assist On/Off Toilet Bathroom Safety Bedpan Assist Bowel Incontinence Assist Change Diapers Wipe Down Catheter Care Assistance Hands-On Assist Standby Assist Verbal Reminders

Nutritional Services (Select all that apply)

Encourage Fluids Encourage Eating Feeding Assistance Prepare Meals Record Food Intake Record Liquid Intake

Medication Services (Select all that apply)

Assist with Insulin G-Tube Meds Insulin Syringe Fill Medication Administration Medication Reminders Oxygen Care

Feeding (Select all that apply)

Spoon-fed Assistance Verbal Cue G-Tube G-Tube + Flush Observe While Eating Open Packages

Thanks for contacting us!

We will get in touch with you shortly.

A member of our team will review your intake form and contact you within 24 to 48 business hours to discuss next steps.

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