Care Needs Assessment Name *FirstLastPhone Number *Email *I need care for: *MyselfFamily MemberFriendOtherHelp is needed because the client is: *AgingDisabledChronically illExperiencing Dementia or Alzheimer'sRecovering from surgeryRecovering from a strokeOtherCaregivers are needed to help with which activities? *HousekeepingMeal preparationShowering or bathingMedication remindersIncontinenceLaundryRespite careAssistance with hospice careTransportationRunning errandsFall prevention assistancePre-/post – surgical assistanceDressing or getting readyWellness checksContacts available in the local area: (check all that apply)MyselfFamily member(s)Friend(s)Volunteer(s)No one at this timeCare is needed on which days of the week? *MondaysTuesdaysWednesdaysThursdaysFridaysSaturdaysSundaysHelp is needed during these times: *Morning (6 -11:59 am)Afternoon or evening (12 - 6 pm)Overnight (10 pm - 6 am)Around the clock (24 hours)CustomCare is needed for how many hours? (duration) *2 - 4 hours per day4 - 6 hours per day6 - 12 hours per day12 or more hours per dayComments: CommentSubmit
