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Monday - Friday, 9AM to 5PM
Call us now (814) 710-3122
Golden Hands Home Care
Home
Forms
Schedule Change
Child Attestation
Member Survey
Consumer Application
Agreement To Care
Home Visit Intake
Login
Consumer Intake Information
First Name
Middle Name
Last Name
Address
Date Of Birth
Social Security Number
Name Of MCO
Phone Number
Direct Care Worker Name
Direct Care Worker Phone Number
Assessment Date
Marital Status
Married
Single
Divorced
Widowed
Gender
Male
Female
Activities of Daily Living (ADLs)
Meal Preparation
Medication Management
Shopping
Laundry
Housekeeping
Dressing
Locomotion
Transportation
Transfer
Add any other activities here.
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