Comfort Living — Resident Intake Form

How to fill this form: Click any field to type, click circles and boxes to mark them, type signatures at the bottom. When you're done, click Submit to Comfort Living to send your inquiry to us directly — our team will reach back within one business day. You can also Print / Save as PDF to keep a copy for your records. To start over, click Reset Form.

Resident Intake Form

COMFORT LIVING 3920 Sunstream Pkwy
Virginia Beach, VA 23456
(757) 781-0362
info@comfortlivingva.com

Comfort Living is a private senior group home — a residential home, not a licensed medical facility. We provide supportive care: our caregivers assist with daily activities the way family members would, alongside your loved one's healthcare team (physicians, home health, hospice). The information below helps us understand your loved one's needs and coordinate with everyone involved in their care.

Date of Intake:

Referred by:

Target Move-in:

How did you hear about us?

Hospital / discharge planner Senior placement agency Family / friend referral Google search Caring.com / A Place For Mom Facebook Other:

Resident

Full Name Preferred Name Date of Birth Age Gender

Female Male Other

Marital Status

Single Married Widow/er Divorced

Height Weight Religion Veteran

Self Spouse only No

Smoker

Yes No

Primary Contact / POA

Full Name Relationship Phone Alt Phone Email Address POA Scope

Full Medical Financial Limited None

Emergency Contact (if different)

Name Relationship Phone

Resident Location

Currently In

Home (alone) Home (with family) Independent Living Hospital Rehab / SNF Other

Current Address

Health Insurance

Insurance Co. Policy # Group #

Medicare # Secondary / Supp. LTC Insurance

Comfort Living · We Provide Family Loving Care www.comfortlivingva.com · Page 1 of 4

Resident Intake Form · Health

COMFORT LIVING 3920 Sunstream Pkwy
Virginia Beach, VA 23456
(757) 781-0362

Primary Care Provider

Name Practice

Phone Address

Other Providers (Specialists, Home Health, Hospice)

Provider Name	Specialty	Phone	Notes

Diagnoses

Primary Diagnosis Other Diagnoses

Allergies (Medication, Food, Environmental)

Code Status / Advance Directives

Full Code DNR (Do Not Resuscitate) DNI (Do Not Intubate) Comfort Measures Only Living Will / Advance Directive on file Medical POA on file

Notes

Active Medications

Collected for awareness and coordination with your loved one's healthcare team. Comfort Living does not administer medications.

Medication	Dose	Frequency	Route	Reason / Notes

Comfort Living · We Provide Family Loving Care www.comfortlivingva.com · Page 2 of 4

Resident Intake Form · Daily Living

COMFORT LIVING 3920 Sunstream Pkwy
Virginia Beach, VA 23456
(757) 781-0362

Activities of Daily Living

Helps us understand your loved one's daily needs so our caregivers can support them the way family members would, and coordinate with the healthcare team, home-health, hospice, or other caregivers involved in their care.

Ambulation

Independent SBA (Stand-By Assist) CGA (Contact Guard Assist) Walker Cane Wheelchair Bedbound

Transfer

Independent SBA (Stand-By) 1-Person Assist 2-Person Assist Mechanical Lift

Bathing

Independent Setup / Cued Some Help Full Help Bed Bath

Dressing

Independent Setup / Cued Some Help Full Assist

Toileting

Independent Reminders Pull-ups Briefs Catheter Full Assist

Continence

Continent Bladder Incont. Bowel Incont. Both

Feeding

Independent Setup Cued Some Help Full Feed NPO (Nothing by Mouth)

Oral Care

Independent Cued Full Assist Dentures

Grooming

Independent Cued Some Help Full Assist

DME / Supplies (Durable Medical Equipment)

Cognition & Behavior

Cognition

Alert & Oriented Mild Cognitive Impairment Dementia Alzheimer's Limited Verbal

Behavior

Quiet / Pleasant Wandering Sundowning Anxiety Aggression Other (note below)

Vision

Normal Glasses Low Vision Blind

Hearing

Normal Hard of Hearing Hearing Aids Deaf

Behavior Notes

Diet & Food Preferences

Diet Texture

Regular Mechanical Soft Pureed Thickened Liquids Diabetic Low-Sodium

Likes Dislikes

Comfort Living · We Provide Family Loving Care www.comfortlivingva.com · Page 3 of 4

Resident Intake Form · Background & Consent

COMFORT LIVING 3920 Sunstream Pkwy
Virginia Beach, VA 23456
(757) 781-0362

Social History

Hometown Birthplace Past Profession Education

Family Structure Hobbies / Interests

Financial

Guarantor Relationship

Self Spouse Adult Child Other Family Legal Guardian

Guarantor Name Guarantor Phone Guarantor Address

Source of Income Private-Pay Period LTC Insurance Status

Mode of Payment

Check Bank Transfer / ACH Cash Credit / PayPal (fee)

Payment Notes

Reason for Seeking Care

Photo / Media Consent

I authorize Comfort Living Home Care to photograph the resident for use in the home's records, family communications, and (if checked below) limited promotional purposes such as the Comfort Living website and social media. Identifying details will not be shared without separate written consent.

Internal records only Family updates allowed Website / social media allowed No photos / media

Acknowledgment & Informed Consent

Were you provided with multiple options for senior care placement?

Yes No

Did you make the decision to choose our services independently and without any pressure or undue influence?

Yes No

These questions help us confirm that our home is the right fit for your loved one. If either answer is "No," we'd like to talk with you before moving forward — to make sure your decision feels comfortable and well-informed. (Residents referred from Sentara Healthcare or its affiliates are exempt from this gate.)

Referral source applies:

Referred by Sentara Healthcare or affiliate Not a Sentara referral

Text Message Consent (optional)

I agree to receive text messages from Comfort Living Home Care at the phone number(s) provided, regarding care updates, scheduling, billing, and general communication. Message frequency varies. Message and data rates may apply. Reply STOP to opt out at any time, or HELP for help. We do not sell or share your number with third parties for marketing. See our Privacy Policy.

Leaving this unchecked will not affect your inquiry — we simply won't text you.

Agreement & Signatures

By signing below, the resident or legal guardian acknowledges that the information provided is accurate to the best of their knowledge and agrees to the terms outlined in this form.

Resident / Legal Guardian — Signature

Printed Name Date

Comfort Living Representative — Signature

Printed Name Date

Website

Comfort Living · We Provide Family Loving Care www.comfortlivingva.com · Page 4 of 4