Every home hospice enquiry, scored before it reaches your CRM
The intake captures diagnosis status, current living situation, and how soon care needs to begin, plus physician documentation of the terminal diagnosis, so your team knows what a family needs before scheduling a care assessment.
The exact intake your home hospice care leads complete
This is the real 7-question guided intake for Home Hospice Care — the same flow your customers finish before you ever pick up the phone.
What a qualified home hospice care lead should tell you
In-home hospice services for a patient with a physician-confirmed terminal or life-limiting illness, scoped around the home's daily caregiver support, who is coordinating care decisions, and the specific comfort and symptom needs involved.
- Doctor Indicated That Patient
- Patient'S Current Living Situation
- Primary Person Coordinating Care
- Soon Home Hospice Care
- Types Support Patient
- Patient Have Insurance Or
- Someone Available At Home
The questions your team needs answered
Every home hospice care intake asks these — and why each one matters.
| Question | Why it matters |
|---|---|
| Has a doctor indicated that the patient has a terminal or life-limiting illness? | A confirmed terminal or life-limiting diagnosis is the single highest-weighted answer, since home hospice care depends on that medical determination already being in place. |
| What is the patient's current living situation? | Living situation tells your team whether the home environment can support hospice care directly or whether a facility-based option might fit better. |
| Who is the primary person coordinating care decisions for the patient? | Knowing who is coordinating care decisions upfront tells staff whether they'll be speaking with a decision-maker or need to establish one before the assessment. |
| How soon does home hospice care need to begin? | How soon care needs to begin is the largest urgency signal in the catalog, separating immediate referrals from families still exploring options. |
| Which types of support does the patient currently need? | The specific support types selected let staff prepare the right care team members before the first visit. |
| Does the patient have insurance or a benefit plan that may cover hospice care? | Insurance status doesn't disqualify a lead but flags whether a coverage conversation needs to happen alongside the clinical assessment. |
| Is someone available at home to assist the patient on a daily basis? | Daily caregiver availability affects both the lead score and whether respite or additional personal-care support should be discussed at the assessment. |
How Cliont scores home hospice care leads
Every answer is weighted automatically — no manual review required.
Value signals
- Doctor Indicated That Patient: yes
- Within a week
- Within a month
- Someone Available At Home: yes
Urgency signals
- Immediately
See the lead your team receives
Home Hospice Care Lead
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 home hospice care workflows
| Cliont capability | Home Hospice Care application |
|---|---|
| Weighted scoring engine | Terminal diagnosis confirmation and urgency timeline (immediate vs. just exploring) carry the highest point values, so leads ready for near-term care assessments rise above early-stage inquiries. |
| Multi-select support-needs capture | The support-needs question lets families flag pain management, personal care, respite, or equipment needs in one step, giving your team a starting picture before the first call. |
| Document upload prompts | Families are prompted to attach physician documentation of the terminal diagnosis so staff aren't chasing paperwork after the intake is submitted. |
| CRM delivery with structured fields | Living situation, care coordinator, and urgency answers arrive in your CRM as separate fields, not a single free-text note, so staff can filter by home setting or timeline. |
Common home hospice care lead scenarios
Immediate hospice need
A doctor has already identified a terminal illness and the family wants care to begin immediately, with someone available at home daily — the intake flags this as a high-priority match for scheduling right away.
No caregiver home daily
The patient has a confirmed terminal diagnosis but no one is consistently available at home, so the intake surfaces the need for respite or personal care support before your team commits to a home-based plan.
Exploring options early
A family in an assisted living facility is only exploring hospice options a month out, with insurance coverage still unclear — the intake routes this as a lower-urgency lead worth a follow-up rather than an immediate assessment.
No care coordinator designated
No one has been named to make care decisions yet, which the intake records separately from the urgency timeline so staff know to confirm decision-making authority before the first conversation.
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 hospice and palliative care intake templates
Home Hospice Care lead-intake FAQs
How does the intake confirm hospice eligibility before we get involved?
The intake asks whether a physician has already indicated a terminal or life-limiting diagnosis, which carries the heaviest weight in scoring; families who haven't reached that point may be better directed to a Hospice Eligibility Assessment first.
What if the family hasn't decided who coordinates care?
The intake records whether the patient, a family member, a professional coordinator, or no one yet is managing decisions, so staff know upfront whether to expect a designated point of contact on the first call.
How does the form handle uncertainty about insurance coverage?
Families are asked directly whether they have insurance or a benefit plan that may cover hospice care; an unclear answer doesn't disqualify the lead but does tell your team to prepare a coverage conversation before the assessment.
Can this intake tell us if a patient needs more support than home hospice provides?
By capturing living situation alongside the specific types of support needed — like pain management, personal care, or medical equipment — the intake helps distinguish requests that fit home-based care from ones that may need Inpatient Hospice Care instead.
How is urgency captured for hospice referrals?
Families select how soon care needs to begin, from immediate to just exploring, and that answer carries significant scoring weight so time-sensitive referrals surface ahead of early-stage inquiries.
Does the intake ask about caregiver availability at home?
Yes — the form asks whether someone is available daily to assist the patient, which affects both the lead's score and whether your team should raise respite or family caregiver support during the assessment.
Turn home hospice care visitors into qualified patients
Give every home hospice care visitor a guided intake instead of a dead contact form — and get a scored, qualified lead before you book front-desk time.