Clients

Clients are eligible for About Care services if they meet one or more of the following criteria:

• The ability to get in and out of a vehicle
• Individuals isolated without a support system in place to help them meet their basic needs, reduce social isolation, transportation to medical appointments, shopping, and errands.
• Persons undergoing life-saving treatment such as dialysis, radiation- therapy, chemo-therapy, etc.
• Caregivers who, without our services, would be in jeopardy of their own health being compromised.
• Homebound, as defined by Medicare.
• Persons with significant physical or mental health disabilities as defined by Social Security, Medicare, or the Veterans’ Administration.

Note: At this time, we are unable to help individuals with dementia or those confined to a wheelchair. 

If you are interested in becoming a client of About Care, you may complete the following form by yourself, ask a friend, family member, or contact Steve Harvey, Community Outreach Coordinator, at 480.802.2331, Ext. 1, [email protected]. You may also contact Mirely Baca, Care Coordinator, at 480.802.2331, Ext. 3, [email protected].

Date / Time *

Date

Time

Name *

First

Last

Date of Birth *

Age *

Sex *FemaleMaleNon-binaryPrefer Not to SayOther - Enter into Comments

Address *

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Primary Phone

Cell Phone

Cross Streets *

Email Address

House Type *ApartmentCondoHouseMobile HomeTown Home

Marital Status *WidowedMarriedSingleDivorced

Name of Spouse (if applicable)

Is Client a Veteran?

• Yes
• No

Language(s) *

Ethnicity *African-AmericanAsian AmericanCaucasianHispanic or LatinoMiddle EasternMixed EthnicityNative AmericanOther

If "Other, please note in comments.

Is Spouse a Veteran?

• Yes
• No

Emergency Contact *

Emergency Contact Phone *

Relationship to Client *DaughterFamily MemberFriendNew ClientParentSonSpouseOther

Emergency Contact

Emergency Contact's City

StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Who does the Client live with? *

Does client have a pet?

• Yes
• No

What type of pet(s)?

Caregivers in client's home? *

• Yes
• No

Able to retrieve Voicemail? *

• Yes
• No

Able to Text? *

• Yes
• No

Would you like to receive Birthday Cards?

• Yes
• No

Would you like to receive Texts?

• Yes
• No

Can you afford Lyft and or Uber?

• Yes
• No

Please share Client's special interests. *

Referred by: *

Annual Income *

• Very Low ($0 - $12000)
• Low ($12,100 - $29,000)
• Middle ($30,000 - $69,000)
• High ($70,000 and above)

Receiving Benefits *

• Medicare
• Medicaid (AHCCCS)
• SNAP (Food Stamps)
• None

Health and Medical Conditions

• Diabetes
• Heart Issues
• Hypertension
• Lung Issues
• COVID Vaccinated
• Other

Please check all that apply.

Impairments

• Cane
• Hearing
• Oxygen
• Speech
• Walker
• Wheel Chair

Please check all that apply.

Please check the services you are interested in receiving: *

• Computer Assistance
• Friendly Visits
• Minor Home Repairs
• Information & Resources
• Reassurance Phone Calls
• Respite Care
• Shopping & Errands
• Transportation
• Other

Who is completing this form?

First

Last

Relationship to ClientDaughterFamily MemberFriendNew ClientParentSonSpouseOther - Note in Comments

Phone

Comments

FOR ABOUT CARE OFFICIAL USE ONLY

Intake completed by:Steve HarveyMirely BacaIxcel Baca

Entered into Assisted Rides

• Yes
• No

Date Entered

Submit

*About Care is an Arizona Non-Profit Corporation under IRS code 501 (c) (3), your donation is tax deductible; Federal tax identification number 34-2047687. Any additional information can be provided upon request by contacting Ixcel Baca at [email protected], or at 480-802-2331, Ext. 2, for more information.