1
/
of
10
Senior Space
Adult Day Services Participant Admission Packet | Editable Word Intake Forms | Adult Day Care | Customizable Admission Forms
Adult Day Services Participant Admission Packet | Editable Word Intake Forms | Adult Day Care | Customizable Admission Forms
Regular price
$7.99 USD
Regular price
Sale price
$7.99 USD
Couldn't load pickup availability
⚠ Duplicate - remove this block
⭐ Build a Complete Adult Day Services Intake Packet — Instantly ⭐
Give your program a professional, organized, and customizable enrollment package without starting from scratch.
The basics to build a new adult day services participant enrollment package, from first contact to a complete record, in one editable Word file.
This Participant Admission Packet gives you five ready-to-edit forms built specifically for adult day services / adult day care centers.
Replace the bracketed placeholders with your program's name, logo, and details, then add or remove fields so the packet fits your model of care and payer mix.
📂 Inside the Packet
Each form is thoughtfully structured for real-world adult day operations, helping you streamline intake, support compliance, and maintain clean participant records.
- Admission Packet Contents Intake Checklist.
A staff checklist to track every required item as it is completed and filed in the participant record.
- Admission Application and Participant Information.
Demographics, services and days requested, transportation and meals, payment and funding source (private pay, Medicaid or waiver, LTC insurance, VA), billing contact, primary caregiver and responsible party, POA, physician, health summary at intake, and referral source.
- Participant Emergency and Contact Notification face sheet.
A first-responder ready page with code status, diagnoses, critical medications, physician and pharmacy, prioritized emergency contacts with pick-up and information-release flags, an authorized and not-authorized pick-up list for legal restrictions, and evacuation needs.
- Activity and Leisure Interest Assessment.
Life history and background, social style and communication, a past-and-present leisure interest inventory, and preferences and routines including triggers to avoid and what calms or re-engages the participant.
- ADL and Functional Assessment.
A 13-item ADL rating grid, mobility and safety, fall and elopement risk, cognition and communication, behavior and sensory, plus a summary and care considerations section with a reassessment date.
👥 Who It’s For
Adult day services and adult day care directors, program coordinators, social workers, and case managers who need a clean, professional intake packet without building one from scratch.
💻 Format & Use
Instant digital download.
One editable Word document you can fill on screen and customize to your setting.
No physical item will be shipped.
⚠️ Please Note
Health requirements such as how often a physical exam, TB test, or TB screening is required vary by state and by program type and they change. The health fields are left open rather than assuming a schedule. Confirm the required items and their frequency against your state licensing regulations and your state or local TB control program before putting this packet into use.
Because this is an instant download, all sales are final. If anything is unclear, message me before purchasing and I am glad to help.
🎁 Bonus Included
Client Rights (Edit it to align with federal, county or your state’s regulations), Photo / media consent & Grievance and Complaint Procedure
It is your responsibility to make sure these forms align with your regs as each state has different requirements. The good thing is, you can change anything in these forms!
Share
