Preliminary Assessment Form
This form is designed to collect as much information about your situation as possible so that when we contact you, we can have a general idea of the necessary level of care
Name of Person you are inquiring for?
Relationship to the Person you are inquiring for
Best Method of Contact
Best Time To Reach You
Check off things that apply to your situation
Seeking New Living Situation
Struggles Performing Basic Living Functions
History of Falls
Lost a Key Support Person
Notice Lack of Personal Hygiene
Having Trouble Maintaining Household
Needs Assistance with Bill Paying
Recently Diagnosed with a Life Threatening Illness
Suspected Elder Abuse
Are they currently receiving Home Care Services?
If they are; are their needs being met with the Home Care Service?
Do they have a problem with hoarding?
If they do have a problem with hoarding, are they facing eviction?
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