New Client Intake & Needs Assessment

Hearts & Minds Patient Advocacy INC

New Client Intake & Needs Assessment Form

Mission: We provide support and advocacy for patients and their families as they encounter health obstacles. Vision: Each patient and/or family member feels adequately supported and heard during their health endeavors improving their healthcare experience.

Section 1: Client/Patient Contact Information

First name

Last name

Birthday

Month

Day

Year

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Primary Language Spoken:

Primary Support Person/Next of Kin:

Contact Phone for Support Person:

Section 2: Patient Profile & Demographics

Please check the category(ies) that best describe the patient’s situation, based on our target populations

A. Patient Status:

A. Patient Status:

Elderly (Needs help with day-to-day tasks or wellness checks)

Critically Ill (Debilitating illness/terminal condition)

Disabled Person (Handicap needing help with daily tasks/resources)

Expecting Mother (Need help adjusting or attaining post-partum resources)

Family of Patient (Seeking support for their role as a primary caregiver)

Low-Income Family

Other Chronic Condition

B. Referral Information: How did you hear about Hearts & Minds?

Section 3: Specific Advocacy Needs Assessment

Please check all areas where you or your family require immediate support. This information will be used to develop your strategic support plan.

A. Healthcare and Coordination

Need to be accompanied to doctor appointments (regular or specialist)

Need assistance with regular wellness checks

Need help understanding or adjusting to a new diagnosis/illness

Need help coordinating with multiple healthcare providers (doctors, specialists, therapists)

Need assistance with hospital discharge planning

B. Resources and Logistical Support

Need help attaining financial resources (e.g., government aid, grants)

Need help attaining post-partum resources (for expecting mothers/families)

Need assistance with housing instability

Need assistance with day-to-day tasks related to the illness/condition

C. Financial and Legal Planning

Need help with financial management related to illness

Need assistance with will planning or other legal directives

D. Isolation and Social Support

I feel I have minimal support (isolated or no next of kin)

My family/support system is also struggling and needs assistance

Section 4: Current Situation (Narrative)

Please briefly describe your primary medical challenge and your most urgent need right now.

Current Medical Challenge:

Most Urgent Need for Advocacy:

New Patient Intake & Needs Assessment Form

Consent Form

Download New Patient Form

Download Consent Form