Where do you currently live? * ? If your situation isn’t listed, select ‘Other’ and type it in.
If no, what areas do you need assistance with? * ? If your situation isn’t listed, select ‘Other’ and type it in.
(If different from client, or if client needs assistance with decision-making)
Are you legally authorized to make decisions for the client regarding financial/legal matters? * ? If yes, please specify (e.g., Power of Attorney, Guardianship)
Are you currently receiving any home healthcare or other in-home services? * ? If yes, please describe:
Do you have any concerns about your memory or cognitive abilities? *? If yes, please explain:
Are you currently taking any medications (prescription or over-the-counter)? * ? If yes, please list them with dosage and frequency
Do you have any vision impairments? * ? If yes, please describe
Do you have any hearing impairments? * ? If yes, please describe
Are you able to communicate your needs effectively? * ? (If no, please explain)
Do you have a strong support system (family, friends, community groups)? * ? If yes, who are your primary support people?
Do you participate in any social activities or hobbies? * ? If yes, please list them
Do you experience feelings of loneliness, isolation, or depression? * ? If yes, please explain
What is your primary source of income? * ? If your situation isn’t listed, select ‘Other’ and type it in.
Do you have health insurance? * ? If yes, what type? \Medicare \Medicaid \Private Insurance \ Other
Are you concerned about your ability to afford future care or living expenses? * ? If yes, please explain
