Client Intake | Blue Star Home Care

Home
About Us
Services
Who We Serve
Careers
Client Intake
Contact Us

Schedule an appointment

Home
About Us
Services
Who We Serve
Careers
Client Intake
Contact Us

Schedule an appointment

CLIENT INTAKE QUESTION SET

Caller Name*

Relationship with Client*

Client Name

Client Age

City & States

Preferred contact method

Direct Call

Email

Type of care needed*

Desired start date

Frequency of care

Email*

Client Living situation

Mobility or cognitive concerns

Pets in the home

Yes

No

Payment method

Private Pay

LTC

VA

Not Sure

Insurance carrier (if applicable)

Veteran or surviving spouse status

Yes

No

Willingness to start private pay if needed

Yes

No

Preferred schedule

Caregiver preferences

Home access considerations

Consultation request

Coverage review

Immediate start date

Best follow-up time

Contact Us

info@bluestarventurellc.org

617-571-5037

© 2025. All rights reserved.

15 South Street ; Apt 1 Lynn MA 01905