Pediatric home-care intake

Tell us how much help your child needs

Choose the answer that best describes what usually happens during the past 7 days. We ask the child’s date of birth because the same amount of help may be expected for a younger child but unusual for an older child.

This is an intake form. A nurse will review the information and make any clinical or service decision.

Child and contact information
The child must be between 1 and 18 years old.
Medical, developmental, and clinical background
Use ordinary language. A nurse will verify diagnoses and medical records later.
Describe what would be incomplete, unsafe, painful, or medically risky without hands-on help.
Doctors, nurses, therapists, and existing documentation

Daily activities

For each activity, tell us the amount of help, how often help is needed, why help is needed, and whether the ability has changed.

Eating

Bringing food or utensils to the mouth, chewing and swallowing safely, and completing the meal.

Thinking about most meals during the past 7 days, how much help does your child need to eat?
Why is help needed? Select all that apply.
Which statement best describes how this ability has changed?
Which parts require physical help?
Select the exact parts the helper touches, lifts, moves, washes, feeds, dresses, steadies, or completes.
Describe what your child does independently or with reminders.
Describe touching, lifting, moving, washing, feeding, dressing, steadying, or completing parts of the activity.
Examples: rest breaks, pain, spasticity, behavioral distress, medical equipment, skin care, or multiple attempts.
Moving around

Walking or moving with the child’s usual wheelchair, gait trainer, walker, braces, or other equipment.

How much help does your child usually need to move around inside the home?
Why is help needed? Select all that apply.
Which statement best describes how this ability has changed?
Which parts require physical help?
Select the exact parts the helper touches, lifts, moves, washes, feeds, dresses, steadies, or completes.
Describe what your child does independently or with reminders.
Describe touching, lifting, moving, washing, feeding, dressing, steadying, or completing parts of the activity.
Examples: rest breaks, pain, spasticity, behavioral distress, medical equipment, skin care, or multiple attempts.
Transfers

Standing up, sitting down, getting on or off surfaces, and moving safely between surfaces.

How much help does your child usually need to get in or out of bed, a chair, the toilet, or the tub?
Why is help needed? Select all that apply.
Which statement best describes how this ability has changed?
Which parts require physical help?
Select the exact parts the helper touches, lifts, moves, washes, feeds, dresses, steadies, or completes.
Describe what your child does independently or with reminders.
Describe touching, lifting, moving, washing, feeding, dressing, steadying, or completing parts of the activity.
Examples: rest breaks, pain, spasticity, behavioral distress, medical equipment, skin care, or multiple attempts.
Toileting

Getting on and off the toilet, clothing, wiping, hygiene, and managing continence supplies or a bowel/bladder routine.

How much help does your child usually need with toileting?
Why is help needed? Select all that apply.
Which statement best describes how this ability has changed?
Which parts require physical help?
Select the exact parts the helper touches, lifts, moves, washes, feeds, dresses, steadies, or completes.
Describe what your child does independently or with reminders.
Describe touching, lifting, moving, washing, feeding, dressing, steadying, or completing parts of the activity.
Examples: rest breaks, pain, spasticity, behavioral distress, medical equipment, skin care, or multiple attempts.
Bathing or showering

Getting supplies ready, washing and rinsing the body, drying, and remaining safe in the bathing area.

How much help does your child usually need to bathe or shower?
Why is help needed? Select all that apply.
Which statement best describes how this ability has changed?
Which parts require physical help?
Select the exact parts the helper touches, lifts, moves, washes, feeds, dresses, steadies, or completes.
Describe what your child does independently or with reminders.
Describe touching, lifting, moving, washing, feeding, dressing, steadying, or completing parts of the activity.
Examples: rest breaks, pain, spasticity, behavioral distress, medical equipment, skin care, or multiple attempts.
Dressing

Choosing or setting out clothes, putting on and removing clothing, fasteners, shoes, and braces or orthotics worn with clothing.

How much help does your child usually need to get dressed and undressed?
Why is help needed? Select all that apply.
Which statement best describes how this ability has changed?
Which parts require physical help?
Select the exact parts the helper touches, lifts, moves, washes, feeds, dresses, steadies, or completes.
Describe what your child does independently or with reminders.
Describe touching, lifting, moving, washing, feeding, dressing, steadying, or completing parts of the activity.
Examples: rest breaks, pain, spasticity, behavioral distress, medical equipment, skin care, or multiple attempts.
Grooming

Brushing or combing hair, washing the face, nail care, and routine personal appearance tasks.

How much help does your child usually need with hair, face, nails, and other grooming?
Why is help needed? Select all that apply.
Which statement best describes how this ability has changed?
Which parts require physical help?
Select the exact parts the helper touches, lifts, moves, washes, feeds, dresses, steadies, or completes.
Describe what your child does independently or with reminders.
Describe touching, lifting, moving, washing, feeding, dressing, steadying, or completing parts of the activity.
Examples: rest breaks, pain, spasticity, behavioral distress, medical equipment, skin care, or multiple attempts.
Oral hygiene

Getting supplies ready, brushing all surfaces, rinsing or suctioning when ordered, and completing mouth care safely.

How much help does your child usually need to brush teeth and complete mouth care?
Why is help needed? Select all that apply.
Which statement best describes how this ability has changed?
Which parts require physical help?
Select the exact parts the helper touches, lifts, moves, washes, feeds, dresses, steadies, or completes.
Describe what your child does independently or with reminders.
Describe touching, lifting, moving, washing, feeding, dressing, steadying, or completing parts of the activity.
Examples: rest breaks, pain, spasticity, behavioral distress, medical equipment, skin care, or multiple attempts.
Equipment used by the child
Safety concerns during eating, movement, or hands-on care
Select every concern that applies.
Caregiver workload
Current services and requested support
Which services or supports does your child currently receive?
Describe different tasks, times, and goals. The nurse will review whether services overlap.
Add the usual times for current services and the support being requested. Leave unused rows blank.
Current schedule 1
Tasks during this time
Current schedule 2
Tasks during this time
Current schedule 3
Tasks during this time
Requested support schedule
Requested schedule 1
Tasks during this time
Requested schedule 2
Tasks during this time
Additional questions that help us prepare a complete nurse review
These questions are selected from recurring documentation gaps found in prior completed cases. They do not determine approval.
Choose the answer that best distinguishes reminders or watching from physical help.
Describe the different tasks, times, and goals so the nurse can review possible overlap.
Describe the transfer, lifting, behavior, equipment, or safety reason.
Tell us what has been tried and what the equipment does not safely solve.
Describe what your child does and what the helper physically does. Watching, reminding, and physical help are different.

Information submitted through this form is used to contact you about services and to support clinical intake review.

This intake form is not a diagnosis, emergency service, final eligibility decision, or substitute for a nursing assessment. Call 911 for an emergency.