Effective Date
Instructions
Updated: 3/2026
Purpose
To collect initial intake information for applicants for Older Americans Act services.
Procedure
When to Prepare
Complete the Intake form to collect demographic information, contact information, and other information needed for the coordination of appropriate services for each person requesting services. Items marked with an asterisk are required for federal reporting and must be completed.
Number of Copies
Complete an original and keep original on file.
Transmittal
Area Agencies on Aging must follow their policy and procedures for Intake. Enter the Intake data in the State Unit on Aging Program Uniform Reporting System (SPURS).
Detailed Instructions Area
Agency on Aging of — Enter the name of the Area Agency on Aging.
Release of Information and Client Rights and Responsibilities — Check the box after explaining the Release of Information and Client Rights and Responsibilities to the person.
Part 1 - Recipient Identification To be completed by AAA or provider staff.
Date — Enter the date of information collection.
SPURS ID No. — Enter the person’s identification number generated by SPURS, if known.
Primary Language — Enter the person’s primary language.
Last Name — Enter the person’s last name.
First Name — Enter the person’s first name.
MI — Enter the person’s middle initial.
Street Address and Apt No. — Enter the street address and, if necessary, apartment number where the person lives.
City — Enter the city where the person lives.
State — Enter the abbreviation of the state where the person lives. For example, enter TX for Texas.
ZIP Code — Enter the ZIP code where the person lives.
County — Enter the county where the person lives.
Area Code and Phone No. — Enter the person’s area code and phone number. Check the box which shows if the number is for a home phone, cell phone, or other type of communication.
Date of Birth — Enter the person's date of birth.
Sex — Check the box which shows the person’s sex.
Email Address — Enter the person’s email address.
Mailing Address — Check the box which shows if the person has a mailing address different from the residential address.
Street Address and Apt No. or P.O. Box — Enter the person’s mailing address and, if necessary, apartment number or P.O. Box.
City — Enter the city where the person receives mail.
ZIP Code — Enter the person’s mailing ZIP code.
County — Enter the county where the person receives mail.
State — Enter the abbreviation of the state where the person receives mail. For example, enter TX for Texas.
Ethnicity — Check the box showing the person’s ethnicity. Check Unknown if the person refuses to answer.
Race — Check the box which shows the person’s race.
Marital Status — Check the box which shows the person’s marital status. Check Not Reported if the person refuses to answer.
Person Lives Alone? — Check the box which shows if the person lives alone or lives with other people.
Total Number of People in Household — Enter the total number of people living in the same household as the person requesting services.
Monthly Household Income — Enter the total household income from all sources.
At or Below Poverty? — Check the which shows if the person’s income is at, below or above the federal poverty level. Use the current Department of Health and Human Services Federal Poverty Guidelines for the size of the household to determine if the person is or is not in poverty.
Monthly Income From — Enter the monthly income amounts for the person and their spouse.
Have you ever served in the United States Armed Forces or Texas Military Forces, regardless of length of service or type of discharge? – Check the appropriate box.
Part 2 - Service(s) Requested —AAA or provider staff complete.
List of Requested Services — Enter notes about the type of help the person needs.
Are you enrolled in? — Check the box which shows if the person is enrolled in Medicare, Medicaid or both.
Part 3 - Emergency Contact Information — AAA or provider staff complete.
Contact Name — Enter the first and last name of the person’s emergency contact.
Relationship — Enter the emergency contact person’s relationship to the person.
Area Code and Phone No. — Enter the area code and phone number of the person’s emergency contact.
Primary Care Physician — Enter the first and last name of the person’s primary care physician.
Area Code and Phone No. — Enter the area code and phone number of the person’s primary care physician.
Part 4 Referral — AAA or provider staff complete.
Referred By — Check the box which shows how the person was referred to the Area Agency on Aging or provider.
Name of AAA or Provider Staff Completing the Intake — Enter the first and last name of the AAA or provider staff who completed the intake.
Date — Enter the form completion date.
Part V- Nutrition Services — AAA or provider staff complete.
Additional Eligibility Requirements — Check the boxes which show why a person under 60 is receiving a congregate or home delivered meal.