Brookside Farm Intake Form

Brookside Farm Client Questionnaire

At Brookside Farm, our goal is to provide the best possible environment for adults with special needs. To help us understand if we’re the right fit for your loved one, please complete this intake questionnaire. This information is kept confidential and will guide us in finding the most supportive placement option.

Section 1: Basic Information

Name of potential resident: Age:

21–25
26–40
41–60
60+

Gender:

Male
Female
Other

Section 2: Care Needs

Has your loved one been diagnosed with any of the following? (Check all that apply) What type of daily assistance is needed?

Minimal (mostly independent, occasional reminders)
Moderate (help with meals, medication, and daily structure)
Full support (assistance with bathing, dressing, eating, etc.)

Section 3: Social & Lifestyle Fit

How does your loved one typically do in social settings?

Enjoys group activities
Prefers small groups/one-on-one
Struggles with social interactions

Does your loved one enjoy participating in structured daily routines?

Yes
Sometimes
No

Are there specific activities or hobbies that your loved one enjoys? (Check all that apply)

Outdoor activities (gardening, walks, sports)
Creative activities (art, music, crafts)
Life skills development (cooking, chores, learning new tasks)
Other:

Section 4: Safety & Medical Considerations

Does your loved one have any medical conditions we should be aware of?

Yes:
No

Has your loved one shown behaviors that could be unsafe to themselves or others?

Yes:
No

Section 5: Family & Placement Goals

What is your primary goal in seeking care with Brookside Farm?

Long-term residential placement
Respite care/short-term stay
Transition support (from school to adult care)
Other:

What are your expectations for the care environment? (Check all that apply)

Safety and structure
Social opportunities and activities
Skill-building and independence
All of the above

Section 6: Budget & Financial Planning

What is your estimated monthly budget for residential care? What funding sources will be used to cover care costs? (Check all that apply) Are you open to discussing financial planning options with our team if your preferred care plan is above budget?

Yes
No

Section 7: Timeline & Next Steps

What is your preferred timeline for placement?

Immediate (1–4 weeks)
Soon (1–3 months)
Future planning (3+ months)

Would you like to schedule a tour of Brookside Farm?

Yes
Not at this time

Section 8: Your Contact Information

Please provide your contact details so we can follow up with you regarding the placement process.

Your Name: Your Email: Your Phone Number:

Thank you! Your questionnaire has been submitted successfully. We will contact you soon.