Intake Form

The Queen (♕, ♛) is the most powerful piece in the game of chess. She can move any number of squares vertically, horizontally, or diagonally—combining the abilities of both the rook and the bishop. Each player begins the game with one queen, placed beside the king in the center of the first rank.

Home care operations are much like a game of chess. Your scheduler, recruiter, on-call team, and administrative staff must be able to think strategically, solve problems quickly, and manage logistics with precision.

Just like the queen on the chessboard, they must anticipate moves ahead of time—predicting the consequences of their actions and understanding how each decision can affect the entire team, your caregivers, and ultimately the clients you serve.

At Home Care Admin Experts, our team is trained to think several moves ahead—ensuring your agency operates smoothly, efficiently, and with the strategic coordination required in today’s fast-paced home care industry.

Home Care Admin Experts Intake Form

Please fill out the information below and provide as many details as possible to be able to provide you with an accurate quote on all our home care solutions.

If you have any questions regarding our solutions, please refer to our Client Handbook
or speak with your designated representative. All information relayed on this form will remain private.

Agency Name and LLC If Applicable

Date

Phone Number

Address. Please include City, State, and Zip Code

Number of ACTIVE Clients and Avg. Bill Rate

Number of Average Billable Hours PER WEEK (Last 4 weeks)

Number of ACTIVE Caregivers and Avg. PAY Rate

Hours of Business Operations in EST

Do you accept Medicaid/Medicare/VA/TBI Insurance or programs, if so list them:

List All Holiday or Days Of Year Business Office is Closed:

Who handles your after hours service inquiries if a potential client calls?

MATCHING YOU WITH THE BEST EXPERT FOR YOUR NEEDS IS IMPORTANT. BE PATIENT WE ARE ALMOST DONE!

KEY PERFORMANCE INDICATORS

How long has your most senior caregiver been with you?

How long has your most senior office staff member been with you?

How many new hires do you hire per week:

How many new clients do you start per week?

How many caregivers do you terminate per week?

How long has your office been open?

CALL VOLUME

When Calling Your Office Do you have a prompt for each department?

Estimate Number of Calls Per Day During Business Hours

Estimate Number of Calls Per Week When Office is closed and CALL offs

ORIENTATION AND RECRUITING

On a Scale from 1-10, Rate your Caregiver's Accountability:

Do you have experience recruiting virtually?

Are your caregivers trained on electronically clocking in and out?

Describe your orientation process in detail if interested in recruiting services:

COMMUNICATION

Do you accept Text Messages from Clients and Caregivers to Communicate After hours?

Do you allow NON-emergency calls after hours?

Are you opposed to informing caregivers to minimize contacy for any reason other than a change in client condition, fall, or 911 inspired emergencies from 12am-6am?

ON-CALL PHONE NUMBER
We will provide a dedicated phone number for after-hours services. Your office will forward all after-hours calls to this number when your office is closed.

Please provide the area code you would prefer us to use when we establish your on-call number.

There is an additional charge of $47.00 per month per number for this service.

RECRUITING PHONE NUMBER
Recruiting services are conducted during normal business hours using our private recruiting line.

A separate number is not required for recruiting services, and subscription phone service rules do not apply to recruiting operations.

SCHEDULING & VIRTUAL ASSISTANCE (BUSINESS HOURS)
For remote daytime scheduling or virtual assistance services during business hours, our team will operate directly within your existing VOIP system.

All calls will be placed as if they are coming directly from your office, allowing our team to function seamlessly as an extension of your internal staff.

Which VoIP system do you currently utilize? (We recommend RingCentral or Unite)

CONFIDENTIALITY NOTICE: This information/email/sheet, including all attachments, is for the sole use of the intended recipient(s) and may contain confidential information. Any unauthorized review, use, disclosure, alteration, or distribution is strictly prohibited and may violate state or federal law.

Please Print Your First, Last Name, and Title

Signature

Thanks! We’ll send you a qoute within 24-48 hours after an initial consultation.

(727) 810-3943

info@iheart-hc.com

Our Company is based out of Florida,USA

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Copyright Home Care Admin Experts. 02/2024.

Florida based.

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Copyright Home Care Admin Experts. 02/2024. Florida based.

Join our PRIVATE Facebook group: Click on image!

Copyright Home Care Admin Experts. 02/2024.

Florida based.