IKOR Intake Form -

Please complete the customer/client form below to the best of your ability. It's perfectly okay if you're unsure. Our team will help clarify everything with you after submission.

Section 1: Client and Contact Information

Client's Full Name

Date of Birth

Current Living Situation

Primary Decision Maker

Primary contact name and relationship (if not client)

Primary Contact Email

Primary Contact Phone

Referring party (if applicable):

Section 2: Known or Reported Challenges

Please describe areas where you believe support may be needed (see examples below)

Functional (mobility, daily living tasks, safety)

Medical (health management, medications, advocacy)

Psychosocial (mental health, cognition, emotional, or social needs)

Environmental (housing safety, home modifications, community access)

Financial (bill management, financial protection, ensuring resources)

Fiduciary (IKOR acting as POA, or supporting family POA or guardianship in care decisions)

Decision-Making Dignity (ensuring appropriate representative arrangements, coordinating with legal professionals, safeguarding client wishes)

Care Planning and Coordination (ensuring cohesive care at home, facility, and insurance systems, reviewing long-term care insurance coverage, supporting claims processes, aligning providers, addressing caregiver needs, and advocating for comprehensive, client-centered solutions)

Urgent or immediate concerns we should prioritize

Section 3: Existing Supports

Does the client currently have:

Please list the relevant names and contact details that you feel comfortable sharing:

Guardian or POA?

if yes, provide name and contact information

Financial Advisor, Trustee, or Attorney involved?

if yes, provide name and contact information

Family members or others actively supporting?

Are the support systems local and capable of meeting the individual's needs?

Are they at a distance?

Any additional clarifications about the family situation

Section 4: Financial Considerations

Have you explored your vision for long-term care and the associated costs?

Would you like us to help you make a financial decision about long-term care, instead of making decisions based on emotion or the circumstances as they evolve?

Are you or the responsible party aware of and prepared for the professional fees associated with IKOR's services?

We are skilled at supporting clients in getting the care they need, regardless of their financial circumstances. Are there significant financial pressures or limitations impacting care planning that we should be aware of?

Any additional information about the financial considerations?

Section 5: Consent and Agreement

I understand that IKOR usually conducts a professional, independent assessment across multiple life areas to ensure all needs and risks are identified, even if I or my family already have specific concerns or requests.

I agree to collaborate with IKOR by providing the necessary records, background information, and access to complete this assessment.

I understand that services provided by IKOR are fee-based and will be clearly outlined before they begin, following the signing of a service agreement.

I understand that IKOR may coordinate with healthcare teams, financial representatives, or legal professionals (when appropriate) with proper consent, but does not provide direct legal services.

Submission Agreement

I understand that by checking this box it is the same as a signature and that all information submitted is correct to the best of my knowledge