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All required fields are marked by a red asterisk*
Consumer Identification & Demographics
Public Intake ID: Getcare ID:
Last:*
Suffix:
First:*
MI:
DOB: *
Age:
(DOB or Age is required for Meals)
AKA Last Name:
AKA First Name:
Medicare ID:
Intake Demographics
Race:*
Edit
Please select atleast 1 race.
Ethnicity
If other, please specify:
Primary Language:*
If other, please specify:
English Fluency:*
Gender:*
If other, please specify:
Sexual Orientation or Sexual Identity:*
If other, please specify:
Does consumer receive SSI?*
Does the consumer want to be screened for CalFresh benefits?*
Address: *
Type:
County:
Apt/Bldg/Suite/Rm#:
Valid Dates From:
Cross Street:
Residence Entry Information:
Phone Number: *
Type:
Valid Dates From:
To:
Please select which intakes you would like to complete
HDM eligibility criteria: A resident of San Francisco 18 years of age or older who is homebound by reason of illness, disability, isolation, lack of support network, and has no safe, healthy alternative for meals.
Does the client consent to services? *
If not, please do not proceed with this application.
Referent Information
Referent Role *
Referent Department *
Client ID in Referring Department (if available)
Relationship to Consumer *
Organization *
Other Community Agency:
Professional
Contact Name: *
Best Time to Reach Contact:
Address:
Type:
County:
Apt/Bldg/Suite/Rm#:
Valid Dates From:
Phone Number: *
Type:
Valid Dates From:
To:
How did you hear about us?
If other, specify:
Save Contact
Residence Discharge Information
Residence Eligibility
San Francisco Resident *
Placed outside of San Francisco?
Living Situation
Housing Type: *
Lives Alone: *
# of others in household *
Household Members' Relationship to Consumer:
Consumer is currently *
Target Discharge Date
Facility Name *
If other, please specify:
Room, Bed, Floor
Choose Previously Entered Contact:
Contact Name: *
Address:
Type:
County:
Apt/Bldg/Suite/Rm#:
Valid Dates From:
Phone Number: *
Type:
Valid Dates From:
To:
Save Contact
Institution/Assisted Living Details
When did the consumer move to the institution/assisted living?
Is the previous residence still available to them if they left the institution/assisted living?
Was the consumer discharged from an SNF in the last 6 months?
Will client likely be eligible for California Community Transition Program (CCT) upon discharge from SNF?
Was Consumer Discharged From Facility Within the Last 30 Days?
Discharge Diagnosis *
Date of Most Recent Discharge: *
Independent Housing Details
Independent Housing Type
Are there formal supportive services in the building?
Other Residence/Living Situation Details (if applicable):
Explain:
Special Circumstances
Spouse/Other IHSS Recipient
Any other IHSS recipients at home?*
Street
Apt/Bldg/Suite/Rm#
State
City
Zip
Is Consumer Married?*
Spouse's Information
Choose Previously Entered Contact:
Spouse's Name: *
Address:
Type:
County:
Apt/Bldg/Suite/Rm#:
Valid Dates From:
Phone Number: *
Type:
Valid Dates From:
To:
Save Contact
DOB:
Gender:
SSN
Is spouse an IHSS recipient? *
Would spouse benefit from IHSS? *
Is the spouse able to do housework? *
Why is the spouse unable to do housework?* *
Spouse's doctor information
Specialty
Facility
Contact Name:
Address:
Type:
County:
Apt/Bldg/Suite/Rm#:
Valid Dates From:
Phone Number: *
Type:
Valid Dates From:
To:
Meal Request
Meal Request Status: *
Request Date: *
Is this an Emergency Meal Request?
Please call DAS Intake at (415) 355-6700 for any Emergency HDM request to determine eligibility.
Who should the meal vendor call to start services? *
Meal support system *
Note: *
Is consumer at or below 300% of the Federal Poverty Level?
Select Diet Type *
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Meal Preference:
Meal preference availability is impacted by the client's home address. If you have a specific preference, please call DAS Intake at (415) 355-6700 to verify meal type availability.
Able to Reheat Frozen Food? *
Food Allergies
Desired Days
Emergency Home-Delivered Meals Contact
Choose Previously Entered Contact:
Relationship *
Contact Name: *
Address:
Type:
County:
Apt/Bldg/Suite/Rm#:
Valid Dates From:
Phone Number: *
Type:
Valid Dates From:
To:
Save Contact
Remove Contact Add New Contact
Financial Information*
Monthly Income
SSI
Social Security
Other Income
Total Monthly Income
Assets
Savings/Checking
Retirement Accts
Other Assets
Total Assets
Major Expenses
Rent
Other
Total Expenses
Other Note:
Note:
Insurance Information
Is consumer enrolled in Medi-Cal?
Is consumer enrolled in Medicare Part A?
Is consumer enrolled in Medicare Part B?
Is consumer enrolled in SFHP? *
Does the client live in the community and meet the SNF Level of Care (LOC) criteria? *
Additional Information: *
Does the client require lower-acuity skilled nursing, such as time-limited and/or intermittent medical and nursing services, support, and/or equipment for prevention, diagnosis, or treatment of acute illness or injury? *
Additional Information: *
Does the client have any social needs (e.g., food insecurity, housing needs, exposure to trauma, social isolation, etc.) that influence their health? *
Additional Information: *
Is the client able to reside continuously in the community with wraparound supports? *
Additional Information: *
Name
#
Other Circumstances
Financial
Total Monthly Income *
Medical
Diagnoses/Issues *
Safety
Is client at risk of abuse or have history of being abused? *
Explain:
Does client currently or have history of suicidal ideation? *
Explain:
Are there any potential dangers to the worker visiting the client? (e.g., aggressive pet; weapons; property hazards; potentially abusive person on site, etc) *
Physician/Clinic Information
Choose Previously Entered Contact:
Specialty
Clinic
Contact Name:
Address: *
Type:
County:
Apt/Bldg/Suite/Rm#:
Valid Dates From:
Phone Number: *
Type:
Valid Dates From:
To:
Save Contact
Remove Contact Add New Contact
Functional Ability
To what degree do any of the preceding types of Instrumental Activities of Daily Living (IADL's) impact the consumer's ability to manage his/her own affairs?
Activities of Daily Living
Instrumental Activities of Daily Living
Misc
Select Assistive Device(s)*
Medical/Physical Condition
Circumstances
To what degree do any of the following type of impairments impact the consumer's ability to manage his/her own affairsTo what degree do any of the preceding types of Instrumental Activities of Daily Living (IADL's) impact the consumer's ability to manage his/her own affairs?
Environment
Stairs
If yes, how many flights?
Elevator
Appliances *
(Check all that apply)
Psychosocial
Anxiety
Judgment
Depression
Memory
Note
Service Needs
(Note is required if "Needs linkage" or "Has but needs support" is selected)
Housing-related Services *
Home repairs/Modification *
Furniture/Appliances *
In-home/Attendant Services *
Caregiver Needs Support *
Emergency On-Call
Please Note: AAA is unable to authorize emergency on-call IHSS services without a completed health care certification form SOC 873. Please fax this form to AAA Intake at 415-355-2463.
Emergency Response *
Food *
Medical/Dental Items and Services *
Assistive devices & DME *
Day Programs *
Mental Health/Substance Abuse Services *
Case Management *
Money Management *
Other Services *
Additional Information *
What has the consumer/caregiver/provider already tried in order to get the needed support or services? *
Risk Assessment
Please explain any checked items in the Summary below
Support Network
Family/friend support status*
Choose Previously Entered Contact:
Address: *
Type:
County:
Apt/Bldg/Suite/Rm#:
Valid Dates From:
Phone Number: *
Type:
Valid Dates From:
To:
Remove Contact Add New Contact
Note
Emergency Contacts
Choose Previously Entered Contact:
Relationship to Consumer
Contact Name:
Address: *
Type:
County:
Apt/Bldg/Suite/Rm#:
Valid Dates From:
Phone Number: *
Type:
Valid Dates From:
To:
Save Contact
Remove Contact Add New Contact
Summary/Comments
Is this a Purchase Only request?
Organization:
Other Community Agency:
Choose Previously Entered Contact:
Contact Name:
Phone Number: *
Type:
Valid Dates From:
To:
Save Contact
Remove Contact Add New Contact
Tips for engaging client
Additional Services
Please list any other services you currently receive

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Additional Questions
Are you interested in learning more about the following services?
Intake - Information about Grave Disability
Criteria for LPS Review List
(A) Referent believes client is gravely disabled due to:*
(B) Client is believed unable to meet the following basic needs due to grave disability:*
(C) San Francisco residency and location information:*
1. San Francisco resident*
Placed outside of San Francisco?
2. Current location (if different from residential address)*
3. Homelessness*
(D) Referent affirms client contact prior 60 days:*
Additional Information related to grave disability (Reminder: request any available documentation be sent to SFPC@sfgov.org)
Referrals to Alternate Resources
Other resources referred to at intake
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