Assisted Living Short Form

An assisted living facility viability assessment form should cover health, cognitive, financial, and social factors.

What is the individual's current medical condition, including any chronic illnesses or recent hospitalizations?

Can the individual independently perform Activities of Daily Living (ADLs) such as bathing, dressing,
and eating?

Are there any signs of cognitive decline, such as memory loss or confusion?

What is the individual's monthly income and assets available to cover assisted living costs?

What level of social engagement does the individual currently have with family, friends, or community groups?

Does the individual have a support system, such as family or a caregiver, that can assist with the transition?

Does the individual express a willingness to move or is there resistance to the idea of assisted living?

Are there any specific preferences or needs regarding location, facility size, or available amenities?

Full Name of Client

Date of Birth

Current Address

Phone Number

Email Address Send email again

Preferred Language

Marital Status

Spouse's Name (if applicable)

Yes No

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