Get Started – Serena Cura

Philadelphia, PA 19130, United States

Mon – Fri: 8:30 am – 5:00 pm, Sat – Sun: Closed

215-433-5559

Click here

Home
Services
About Us
Contact Us
Get Started

intake Form

Home
Services
About Us
Contact Us
Get Started

Home
Services
About Us
Contact Us
Get Started

6132 Lansdowne Ave Philadelphia PA 19151
Mon – Fri: 8:30 am – 5:00 pm,
Sat – Sun: Closed

215-433-5559

Make an Enquiry

Sign up for appointment

It just takes a few minutes to book a visit online.

Intake Form
PERSONAL INFORMATION
Full Name

First NameLast Name
Gender
Date of Birth

MonthDayYear
Date
Address (if any)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SSN
Phone Number
Please enter a valid phone number.
ID Number
Expire Date

MonthDayYear
Date
State Issued
Email
example@example.com
Primary Care Provider
Preferred Method of Contact

E-mailCell Phone

EMERGENCY CONTACT
Emergency Contact

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

IDENTIFICATION & INSURANCE
Name of Insurer

First NameLast Name
Insurer Phone Number
Subscriber Name

First NameLast Name
Subscriber Date of Birth

MonthDayYear
Date
Subscriber Relationship to Patient
Medicaid or Medicare

MedicaidMedicareVA
Medicaid Number
Policy Number

MEDICAL HISTORY
Please check all the apply

NoneAllergiesAnemiaAnginaAnxietyArthritisAsthmaAtrial FibrillationBenign ProstaticHypertrophyBlood ClotsCancerCerebrovascular AccidentCronary Artery DiseaseCOPD (Emphysema)Crohn's DiseaseDepressionDiabetesGallbladder DiseaseGERD (Reflux)Hepatitis CHyperlipidemiaHypertensionIrritable Bowel DiseaseLiver DiseaseMigraine HeadachesMyocardial InfarctionOsteoarthritisOsteoporosisPeptic Ulcer DiseaseRenal DiseaseSeizure DisorderThyroid DiseaseOther
Do you use tobacco?

NoDailyWeeklyLessFormer User
Do you use alcohol?

NoDailyWeeklyLessFormer User
Caffeine use?

NoDailyWeeklyLessFormer User
Have you been convicted of drug related charges?

YesNo
Please explain the circumstances
Are you currently taking prescription medication?

YesNo
Prescribing Doctor's Name

First NameLast Name
Prescribing Doctor's Phone
Have you had any surgeries in the past 5 years?

YesNo
Please specify:

LEGAL/REENTRY STATUS
Are you currently on parole or probation?

YesNo
Probation Officer

First NameLast Name
Probation Officer Email
example@example.com
Probation Officer Phone Number
Please enter a valid phone number.
Release Date from Institution (if applicable)

MonthDayYear
Date
Name of Last Institution/Facility
HOUSING NEEDS
Room Preference

Shared RoomPrivate Room
Do you require ADA-accessible accommodations

YesNo
Do you have any pets or service animals?

YesNo
If yes, specify
Have you ever been evicted or denied housing?

YesNo
If yes, explain:

MEDICAL & MENTAL HEALTH
Primary Care Physician

First NameLast Name
Primary Care Physician Phone Number
Please enter a valid phone number.
Primary Care Physician Email
example@example.com
Do you have any medical conditions?

YesNo
If yes, list
Do you take medications daily?

YesNo
If yes, list medications and dosages:
Do you receive therapy or counseling?

YesNo
INCOME & BENEFITS
Current Income Source:

SSISSDIEmploymentPensionNone
Amount
Do you have a Payee or Financial Guardian?

YesNo
If Yes Payee or Financial Guardian?

First NameLast Name

SUPPORT SERVICES INTERESTED IN
✔️ All that apply

Assistance with Medicaid or benefitsTransportation to appointmentsDaily living skills trainingJob training or placementCounseling or emotional supportHelp obtaining ID or documentsMedication remindersMeal services

ADDITIONAL INFORMATION
Do you have any dietary restrictions or allergies?
Do you currently use assistive devices (cane, walker, etc.)?

YesNo
Additional comments or concerns

RESIDENT CONSENT & SIGNATURE

I certify that the above information is accurate to the best of my knowledge. I understand that Serena Cura will use this information to determine eligibility and services needed.
Signature

Powered by Jotform SignClear
Date

MonthDayYear
Date
Intake Staff

First NameLast Name
Staff Signature

Powered by Jotform SignClear
*Your signature below indicates that the information you have provided above is truthful.
Should be Empty:

6132 Lansdowne Ave,
Philadelphia, PA 19151

215-433-5559

info@serenacura.com

Our Services

Benefits Assistance
Domiciliary Care
Group Home Residential Care
Community Hab Care
Counseling, Emotional Support, and Crisis Intervention

Subscribe to Our Newsletter

Thank you for subscribing to the newsletter.

Oops. Something went wrong. Please try again later.

Instagram

#1 in Philadelphia for Group Home for Elder & Benefit Assistance

-

Serena Cura

Sign up for appointment

Intake Form

PERSONAL INFORMATION

EMERGENCY CONTACT

IDENTIFICATION & INSURANCE

MEDICAL HISTORY

LEGAL/REENTRY STATUS

HOUSING NEEDS

MEDICAL & MENTAL HEALTH

INCOME & BENEFITS

SUPPORT SERVICES INTERESTED IN

ADDITIONAL INFORMATION

RESIDENT CONSENT & SIGNATURE

Menu

Our Services

Subscribe to Our Newsletter