New Potential Client Inquiry Form

A 5-page Word first-call intake form for office staff when a family calls about home care.

For USA non-medical home care agency owners, intake staff, and supervisors. Plus 1 agency instructions page to remove before use.

What's included

1. Page 1: sections 1-2 call details and caller information
2. Page 2: section 3 prospective client basics, section 4 services interested in, and section 5 schedule wanted
3. Page 3: sections 6-9 payer source, how the caller heard about the Agency, urgency, and next steps
4. Page 4: section 10 consent to contact and section 11 follow-up log
5. Page 5: Agency Use Only lead record
6. Agency instructions page, to remove before use

Add your logo and name

1. Open the Word file and replace the Your Logo Here box with your logo.
2. Replace Agency Name in the letterhead; the body says "the Agency," so no other name edits are needed.
3. Replace the Street Address, City, State ZIP line and the Phone, Email, Website line with your details.
4. Set the letterhead text to black, delete the instructions page, and save.

Customizable template, not legal advice; check your state's requirements. Not a license to operate, not HIPAA software, and no medical claims. Collect only the minimum needed on a first call. Check federal and state rules on calls and texts before follow-up.