In Home Personal Care

8441 Wayzata Blvd., Suite 130
Golden Valley, MN 55426
Phone: 763-546-1000
Fax: 763-546-1018

Testimonial

We cannot express enough how important it is to have In Home to help care for my disabled daughter.
-LaVonne - Parent

Quality Home Care Services by People Who Understand

Getting Started

If you are interested in becoming a valued client of In Home Personal Care, please complete the Intake Form below. If you’re completely new to personal care services, please feel free to call us at 763-546-1000 for information and we will be happy to assist you.

Contact Information Name:
Date of Birth:
Address:
Residing County:
Home Phone:
Cell Phone:

Contact Information (If Not Self) Name:
Address:
Home Phone:
Cell Phone:

Type of Disability Are you looking for assistance with: Personal Care (Grooming, etc.)
Homemaking (Cleaning, Laundry, Errands, etc.)
Both

In the past year, how many times have you been hospitalized?

Any current conditions we should be aware of?

Have you ever been diagnosed with Type I behavioral problems?
If yes, please explain:
What time(s) of day do you need assistance?
Duration of shift needed:
Assistant gender preferred?
Do you see a Public Health Nurse? Yes
No
If yes, date seen:
Name of nurse:
Phone number:
Are you currently with a home care agency?

If yes, list name of home care agency:
How long have you been with them?
Reason for switching:
What is your funding source? Private Pay
Medical Assistance
Number:
Waiver CADI
MR
TBI
Case worker's name:
Phone number:
Is there any additional information you feel would be helpful to us in providing your care?

Whom May We Thank For The Referral? Name:
Home Phone:
Cell Phone: