Needs Assesment

Please assess your care needs.

Share with us what’s most important to you, and we will do the rest

The first section is required information. The second section is optional. However, the more you can share with us, the better we can serve you in finding the right match to your care needs. .

Name of person(s) you are seeking help for:

Senior 1:

Age:

Weight:

Gender:
MaleFemale

Senior 2, Spouse :

Age:

Weight:

Gender:
MaleFemale

Preferred Location Zip Code:

Distance you are willing to travel:

Budget:

Minimum $ :

Maximum $ :

Care needs:

Indicate level of care:

Timing :

Is the Senior 1 or Spouse a Veteran?

Your senior needing care…

This section is optional. However, the more you can share with us, the better we can
serve you in finding the right match for your care needs.

Financial

Funding sources:

*Check all that apply

Personal Funds (Income, Savings, Pensions, Investments)Long-Term Care InsuranceVeterans Aid & AttendanceFamily ContributionMedi/Medi (Medicare/Medi-Cal)SSI (Supplemental Security Income)

What are the biggest challenges you are facing at this time?

*Check all that apply

FinancialMy loved one is unwilling to move into a communityThe idea of downsizingOut-of-town/state relocationAgreement from siblings

My loved one has been diagnosed with

*Check all that apply

Alzheimer’s/Dementia/Memory LossParkinson’sDiabetes, requires injectionsIncontinence (urinary or bowel)

Activities of Daily Living/Care Needs

Medication Management: How many times a day?

Number of Medications:

Bathing & GroomingDressing

Escorting
May need help to be escorted throughout the community

Ambulatory Status:
Able to walk without assistanceNeeds help WalkingUses a Walker (assistive device)Stays in a wheelchair throughout the day

Transfer Assist:
1 Person Transfer2 Person Transfer

Your comments:

Special Care Needs

Mental Health:
DepressionBipolarSchizophreniaAlcoholDrug AddictionIs at risk of wanderingNeeds close supervision

Vision impaired:
Some vision lossMacular DegenerationBlind

Hearing impaired
Some hearing lossDeaf

Has a urinary catheter or colostomy:
Foley CatheterStraight CatheterSuprapubic CatheterHas a colostomy pouch for body waste

Requires Oxygen
OccasionallyContinuouslyRequires a ventilatorHas a feeding tubeHas a tracheotomy tube

Has an open wound requiring care?
YesNo

Has it been staged?
Stage 2 or lessStage 3 to 4

BedriddenBed bound

Is considered overweightObese

Would like to keep a small pet:
DogCatBird

Additional important information you would like to share with us:

Name of the person filling out application:

Email of the person filling out application:

Fill out our needs assessment and we’ll do the rest- FREE of charge!

Needs Assessment