Know which adult day care families deserve a care assessment first
Ask about daily support needs, medication supervision, and mobility equipment before you schedule a visit, then collect medication lists and care plans so staff know what to expect before day one.
The exact intake your adult day care leads complete
This is the real 7-question guided intake for Adult Day Care — the same flow your customers finish before you ever pick up the phone.
What a qualified adult day care lead should tell you
Supervised daytime programming for older adults who need support with daily activities, medication reminders, or social engagement while a caregiver is at work or unavailable. Intake needs to establish how much assistance the person requires and whether medical supervision is involved before a care assessment is scheduled.
- This Care Being Arranged
- Level Daily Support Person
- Person Have Any Medical
- Many Days Per Week
- Day Care Services Begin
- Person Authorized Make Care
- Person Use Mobility Equipment
The questions your team needs answered
Every adult day care intake asks these — and why each one matters.
| Question | Why it matters |
|---|---|
| Who is this care being arranged for? | Segments the lead so you can route, price, and prioritize it correctly. |
| What level of daily support does the person typically need? | The level of daily support needed indicates whether your program's staffing and activity mix can realistically meet the person's needs. |
| Does the person have any medical needs that require staff supervision, such as medication reminders? | A yes on medical supervision signals that staff must confirm they can provide medication reminders or oversight before scheduling an assessment. |
| How many days per week is day care needed? | Segments the lead so you can route, price, and prioritize it correctly. |
| When do you need day care services to begin? | An 'Immediately' start date marks the lead as urgent so staff can prioritize it ahead of families who are still planning without a set date. |
| Are you the person authorized to make care decisions or arrangements for this individual? | Confirming decision-making authority prevents staff from booking a care assessment with someone who cannot actually finalize enrollment. |
| Does the person use mobility equipment such as a wheelchair or walker? | Knowing whether mobility equipment is used lets staff confirm the facility has appropriate space and equipment before the visit. |
How Cliont scores adult day care leads
Every answer is weighted automatically — no manual review required.
Value signals
- Minimal, mainly social engagement
- Some assistance with daily activities
- Significant assistance with most activities
- Not sure
- Person Have Any Medical: yes
- Person Authorized Make Care: yes
Urgency signals
- Immediately
See the lead your team receives
Adult Day Care Lead – Immediate Start
From first click to qualified lead
Follow patients and caregivers through one smooth, guided flow.
They land & meet you
Your video greeting plays instantly — a real face instead of a blank form.
They explain the visit
Smart questions adapt to their visit and capture the full scope.
They share details
Symptoms, history, and documents come attached before the visit.
You get a ready lead
Scored and qualified — waiting for you to win it.
Built for adult day care workflows
| Cliont capability | Adult Day Care application |
|---|---|
| Conditional lead scoring | Automatically raises a lead's priority when medical supervision needs and an 'Immediately' start date are both present, rather than scoring urgency and care complexity separately. |
| Authorization flagging | Routes leads where the submitter answers no to being authorized to arrange care into a follow-up queue instead of directly onto your care-assessment calendar. |
| Structured intake fields | Captures daily support level and mobility equipment use upfront so staff can pre-plan room setup and staffing before the family arrives. |
| CRM routing rules | Sends leads requesting 5 or more days per week into a different pipeline stage than occasional or as-needed requests, so capacity planning stays separate from urgent intake. |
Common adult day care lead scenarios
Immediate start, medical supervision needed
A family answers 'Immediately' for start date and yes for medication supervision — the intake flags this as urgent and high-value so it reaches your team ahead of families still planning.
Authorized family member, significant assistance
An adult child confirms decision-making authority and reports the person needs significant assistance with most activities, producing one of the highest-scoring combinations the intake can surface.
Care coordinator without decision authority
A case manager fills out the form but answers no to being authorized to make care arrangements, so the lead is routed for follow-up to confirm the real decision-maker before an assessment is booked.
Occasional respite, minimal support
A family requests care only 1-2 days a week with minimal support needs mainly for social engagement, and no set start date — a lower-urgency lead your team can schedule around, not rush.
Connect Cliont to your workflow
Send leads
HubSpot, HighLevel, Salesforce, JobNimbus
Book visits
Google Calendar, Outlook Calendar, Calendly
Notify your team
Email, SMS, Slack
Automate follow-up
Zapier, Webhooks, API
Simple, transparent pricing
Choose the plan that works for your business.
Professional
Unlimited intake forms and leads for your growing business.
- Unlimited intake forms
- Custom video greetings
- AI-powered voice bot
- English + Spanish support
- Automatic lead scoring
- Digital estimates & e-signatures
- Photo, video & file upload
- Advanced analytics dashboard
Pay Per Lead
Only pay when you receive a qualified lead.
- Unlimited intake forms
- Custom video greetings
- AI-powered voice bot
- English + Spanish support
- Automatic lead scoring
- Digital estimates & e-signatures
- Photo, video & file upload
- Charged only for submitted leads
More adult day services intake templates
Adult Day Care lead-intake FAQs
How does the intake flag whether a lead needs medical supervision?
The intake asks directly whether the person has medical needs requiring staff supervision, such as medication reminders. A yes answer raises the lead's score and lets your team confirm ahead of time that the program can support that level of care.
What happens if the person submitting the form isn't authorized to make care decisions?
The intake asks whether the submitter is authorized to arrange care for the individual. A no answer scores lower than a yes, which helps your team avoid scheduling a care assessment before confirming who can actually approve enrollment.
Can this intake tell me if a lead is better suited to Memory Day Program instead?
The intake doesn't diagnose cognitive needs, but the level-of-support and medical-supervision answers can indicate when a lead should be referred to your Memory Day Program instead of general Adult Day Care.
Does the intake ask about transportation to the program?
No — transportation logistics are handled by the separate Transportation to Day Program intake. This form focuses on care needs, mobility equipment use, and how many days per week care is needed.
How does days-per-week affect how a lead is prioritized?
The intake captures whether care is needed 1-2 days, 3-4 days, 5 or more days, or occasionally, so you can see capacity implications alongside the urgency of the requested start date.
What does a mobility equipment answer actually tell my staff?
Knowing whether the person uses a wheelchair or walker lets your staff confirm the facility has appropriate space and equipment before the family arrives for a care assessment, rather than discovering it on arrival.
Turn adult day care visitors into qualified patients
Give every adult day care visitor a guided intake instead of a dead contact form — and get a scored, qualified lead before you book front-desk time.