Client Call-In Information
New lead intake — complete all fields during call
Caller Information
Caller First Name
Caller Last Name
Relationship to Client
— Select —
Spouse / Partner
Son
Daughter
Son-in-law
Daughter-in-law
Father
Mother
Brother
Sister
Grandson
Granddaughter
Friend
Neighbor
Social Worker
Hospital Discharge Planner
Doctor's Office
Geriatric Care Manager
Nurse
Insurance Company
Other
Caller Home Phone
Caller Cell Phone
Caller Email
Call-In Date
Day
— Day —
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Time of Call
Taken By
Prospect Information
First Name
Last Name
Preferred Name
Home Phone
Mobile Phone
Email
City
Zip Code
Lives With
Initial Contact Date
Requested Start Date
Referral Source
Referral Source Type
— Select source type —
Internet / Website
Google Search
Facebook / Social Media
TV / Radio
Newspaper / Magazine
Hospital / Discharge Planner
Doctor / Physician Referral
Friend / Family Referral
Senior Living Community
Aging Life Care Manager
VA / Military
Insurance Company
Yellow Pages / Directory
Returning Client
Other
Existing Referrer
— Select referrer —
211 Sacramento
A Place for Mom
A1 Home Health and Hospice
AARP
ACC Care Center
ACC Maple Tree Village
ACC Nursing Home (Asian Community)
Absolute Compassion Hospice
Absolute Hospice
Accent Care
Access Home Care
Action Home Nursing
Adams & Associates
Advanced Health Care Sacramento
Advanced Home Health
Advanced Wellness
Adventist Health - Sonora Cancer Center
Adventist Health Diana J .White Cancer Inst
Adventist Health Wound Care
Adventist Health-Sonora Home Health
Adventist Health-Sonora Hospice
Adventist Hospital of Sonora
Adventist Lodi Home Health
Adventist Lodi Memorial Hosp
Adventist Physical Therapy
Adventist Spine Surgery Institute
Aegis Living
Aging in Place Home Care
AgingCare.com
Alderson Convalescent Hospital
Alignment Health
All About Seniors
Almond Heights MBK
Almond Vista Healthcare
Alpine Orthopedics
Alta California Regional Center
Altamedix Day Care
Alzheimer's Aid Society
Ambulatory Surgery Stockton
American Hospice Home Health
American River Care Home
American River Center SNF
American River Home Health
Angels Camp Family Practice
Apex Care Physical Therapy
Apple Ridge Assisted Living
Applewood Post Acute
Arbor Rehabilitation and Nursing
Arcade Church
Arcade Creek Manor
Arden Post Acute
Area 12 Agency on Aging
Aria Home Health
Arias Home Health
Aries Home Health
Asbury Park Nursing & Rehab Center
Asera Care Hospice
Ashbury Park SNF
Ashley Place
Assisted Living
Associated Family Physicians
Astoria A/L Tracy
Astoria Senior Living/Memory Care
Atria Bayside Landing
Atria Carmichael Oaks
Atria El Camino Gardens
Atria Rocklin
Atrium, The
Atta Home Healthcare
Auburn Oaks
Avalon Care Center-Sonora
Avalon Health Care-San Andreas
Avena Bella
Balance Assisted Living/Memory
Bankers Life
Bell Star Health Care
Belmare Senior Living
Ben Schaffer Cancer Institute
Bethany Homes SNF
Bethel Retirement Community
Blossom Ridge Home Health
Blossom Ridge Home Health and Hospice
Brandel Manor
Briarwood Health Care
Bridge Hospice
Bright Horizons Family Solutions
Brightwood College
Brilliant Care Home
Bristol Hospice Modesto
Bristol Hospice Roseville
Bristol Hospice Sacramento
Bristol Hospice Stockton
Broadway Senior Center
Brookdale Assisted CH
Brookdale Assisted Living
Brookdale Hospice
Brookdale Kettleman Lodi
Brookdale Stockton
Brookdale Sylvan Ranch
Brookdale Tracy
Brookdale at Folsom
Brookdale at Hazel Creek
Brookdale at Roseville Gardens
Bruceville Point
Bruceville Terrace SNF
Buhler Specialty Pavilion
Burger Physical Therapy
CK Employee or Applicant
CK Signage
CK Website Employment Lead
CalPers LTC Ins
Calaveras County Veterans Service Office
Calaveras Health & Human Svs. Agency
California Department of Vetereans Affairs
California Health Collaborative
Camden Springs Retirement
Camlu Assisted Living
Capital Transitional Care
Capitol HealthCare
Care.com
CareOne Home Health
Caregiver Referral Agency
Caring for You Case Management
Carlton Plaza of Sacramento
Carmichael Care & Rehabilitation Center
Catholic Charities of Diocese
Citrus Heights Post Acute Rehab (Manor Care)
Comfort Keepers
Community Hospice
Community Medical Centers
Country House Memory Care of Granite Bay
Dameron Hospital
Dignity Health Cancer Institute
Dignity Mercy General Hospital
Doctors Hospital of Manteca
EK Health
El Dorado Senior Care
Elica Health Services
Emanuel Medical Hospital
Encompass Health Rehab Hospital
Eskaton Care Center Greenhaven
Eskaton Home Health Care
Eskaton Village Carmichael
Eskaton Village Roseville
Facebook
Fair Oaks Health Care Center
Fisher Fiduciary Services
Folsom Convalescent Hospital
Folsom Senior Center
Friend
Genworth Financial
Gold Country Health Center
Golden Pond Senior Living
Good Samaritan Rehabilitation
Health Net
Home Instead
Hospice of San Joaquin
IHSS
Indeed
Independent Living Systems (ILS-Kaiser)
John Hancock LTC Insurance
Kaiser Folsom
Kaiser Foundation Hospital (Morse)
Kaiser Home Health and Hospice Sacramento
Kaiser Roseville
Kaiser Stockton
Kindred Hospital
LTC Insurance
Marshall Hospital
Meals On Wheels
Medicare
Mercy Folsom
Mercy Home Health & Hospice
Mercy San Juan
MetLife Long Term Care
Nextdoor.com
Oakmont of Folsom
Oakmont of Roseville
PACE Sacramento
Previous Client
Previous Employee
Revel Independent Living-Folsom
Right At Home
Sacramento Senior Resources
Senior Care Consulting
Snowline Hospice
Suncrest Hospice
Sunrise Senior Living Carmichael
Sunrise Senior Living Fair Oaks
Sutter Auburn Faith
Sutter Care at Home
Sutter Roseville
UC Davis Med Center Sac
VA-Veteran's Administration
Vitas Hospice Sacramento
Web
WellQuest of Granite Bay
Yellow Pages
Yolo Hospice
ZipRecruiter
myCNAjobs
Prospect Care Needs
Care Goals
Medical Conditions
Alzheimer's / Dementia
Emphysema / COPD
Stroke
Diabetes
Heart Trouble
High Blood Pressure
Oxygen Required
Cancer
Mental / Behavior Conditions
Ambulation Notes
Cane
Walker
Wheelchair
Bed Bound
Hoyer Lift
Transfer Assist
Who Manages Medications / Supplements?
Special Diet
Medications
Breakfast
Lunch
Snack
Dinner
Meal Notes
Driving / Transportation Notes
Personal Care Services
Transfer with Assist
Toiletries
Bed and Shower Baths
Medication Schedule
Oral Care
Dressing Assistance
Incontinent Care
Personal Care Notes
Home Care Services
Meal Preparation
Light Housekeeping
In-Home Companionship
Errands
Grocery Shopping
Laundry / Change Bed Linens
Transportation
Pet Care
Activities
Respite Care
Home Care Notes
Log This Call
Call Date
Description
Call Notes / Primary Concerns
Assignment & Routing Tags
Sales Area (SlsArea)
— Select Area —
Calaveras
CH
EG
Folsom
Modesto
Roseville
Sac
Sonora
Stockton
System
Sales Director (SalesDir)
— Select Director —
Amy
Caren
Caren / Nadra
Nadra
Office
Client Director (ClientDir)
— Select Director —
Aimee
Amy
Caren
Gissel
LeadCG
Nadra
Stephanie
System
Director Follow-Up
Director Name
Director Contact Method
Text Sent
Email Sent
VM Left
Time / Date Director Called Back
In-Person Contact
Logged in WellSky:
Date
Time
Logged By
