Client Intake Form

General Information

Client Name

Address

Social Security #

Birth Date

Home Phone

Cell Phone

Religion

Living Arrangements

MCO

Responsible Party/Conservator/Caregiver

Phone #

Transported By:

If "Other":

Physician Information

Physician Name

Physician Address

City

State

ZIP

Physician Phone #

Physician Fax #

Functional Information

Physical

Cognitive

If "Oriented", oriented to:

ADL

Behavioral Information

Has the applicant wandered with in the last month?

Does the participant need supervision?

Has the participant ever been verbally or physically abusive?

Authorization

I hereby authorize Aramingo Adult Day Care to obtain and/or release dates of admission and/or discharge and other pertinent health information including diagnosis and related treatment from agencies, organizations and health care providers.

How Do I Apply?

Call and request an application from the Director of Adult Day Care.

All admission paperwork will be discussed prior to a scheduled appointment.

Call: (215) 888-6620
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.

An appointment will be scheduled for an interview and further evaluation with the prospective client and his/her family members or caregivers.

All prospective clients are assessed prior to admission.

Convenient Location

Our Aramingo Adult Day Care Center location offer exciting ways to make new friends and enjoy fun activities with others.

3307 Agate St, Philadelphia, PA 19134
(215) 888-6620

Hours of Operation

Monday – Friday

7am – 6pm
Saturday

7am – 4pm
Sunday

Closed

Directions

Aramingo Adult Day Care