REQUEST HELP
ASSESS YOUR NEEDS

1-888-240-7539

Monday through Friday
8:00am to 5:00pm

Needs Assessment

This assessment form was designed to quickly and accurately evaluate your care needs. There are 12 questions; please answer as many as you can. You don't need to answer all the questions, but it is required that you answer question #2. It will take about 5-10 minutes to complete.

When you finish, click the 'Submit' button at the bottom of the form, and we'll recommend care options to meet your needs.

Then you can learn about each option, select those that seem most appropriate and find care providers anywhere in

 

  1. I am seeking care for:

  2.   Myself
      My Parent
      My Spouse
      Another Relative
      My Friend
      Other

  3. I prefer to receive services:(check all that apply)

  4.   In my home
      In the community
      At a residential facility
      In an institutional setting
      I'm not sure

  5. I require assistance with the following tasks:

  6.   Eating
      Dressing/Grooming
      Transferring (from bed into a wheelchair)
      Toileting
      Bathing
      Medication reminders or supervision
      None of the above

  7. I require assistance with the following household chores:

  8.   Cooking
      Shopping
      Telephone Calls
      Money Management
      Transportation
      Light Cleaning
      Heavy Cleaning
      None of the above

  9. My mobility level is such that:

  10.   I walk without assistance
      I use a cane or walker
      I use a wheelchair
      I am homebound

  11. I have experienced symptoms such as:

  12.   Confusion about where I am
      Forget the names of close family members or friends
      I have not experienced the abovementioned symptoms

  13. In my current care situation, I have:

  14.   Periods of more than 24 hours when I am left alone
      Care needs which are often unmet
      Inadequate opportunities to socialize with others
      Family and friends who do not live close enough to visit on a regular basis
      Generally sufficient care for my needs

  15. I am able to pay for services out of pocket:

  16.   Entirely
      Somewhat
      Not at All
      I don't know

  17. My health insurance is issued by:

  18.   The Veterans Administration
      Medicaid
      Medicare
      Long-term care insurance
      Other
      I am not insured

  19. I have the following medical conditions:

  20.   Alzheimer's or Dementia
      Arthritis
      Brain Injury
      Cancer
      Depression, Psychiatric illness
      Developmental disability
      Diabetes
      Heart problems
      HIV/AIDS
      Multiple Sclerosis
      Parkinson's Disease
      Pulmonary (lung) disease
      Recovering from surgery or an infection or injuries
      Stroke
      None of the above

  21. My 2 or 3 most pressing needs are:

  22.   Assistance in developing a plan of care
      Care in case of emergency
      Companionship
      Daily living assistance
      Food
      Housing
      Management of overall service needs
      Rehabilitation (from surgery, an accident,stroke,etc.)
      Skilled nursing care
      Social and recreational activities
      Support in dying
      Transportation

  23. Other services I might find useful are:

  24.   Legal advice or estate planning
      Professional care management
      Support services for caregivers
Counties