Name *

First Name

Last Name

Phone *

(###)

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Current type of residence

Private home with no formal or informal support

Private home with informal support (family/friends)

Private home with formal support (home health, day services, etc)

Private home with both formal and informal support

Other personal care home

Nursing facility

MH/ID Community Settngs

Homeless

Length of time at Current Residence

Less than 3 months

3 months - 1 year

1 - 5 years

5 or more years

Level of Supervision Needed

No supervision required in home or out in community

No supervision at home, but needs attendance in unfamiliar places

Requires supervision in the home, needs attendance when outside the home, and/or tends to wander

Requires regular supervision in the home and cannot leave home unattended

Requires 24-hour direct supervision

Mobility Needs

Independent- Has no mobility needs and can evacuate independently in an emergency

Minimal (Mobile) - requires limited physical or oral assistance to evacuate in an emergency

Moderate (Immobile) - Applicant requires moderate physical or oral assistance to evacuate in an emergency

Total (Immobile) - Applicant requires total physical or oral assistance to evacuate in an emergency from one or more staff persons

Ability to Self-Administer Medications:

Can self-administer without assistance

Can self-administer with assistance in remembering schedule

Can self-administer with assistance in offering medications at prescribed times

Can self-administer with assistance in opening container or locked storage area

Cannot self administer

Activities of Daily Living

Eating

Drinking

Transferring in/out of bed/chair

Toileting

Bladder Management

Bowel Management

Ambulating

Personal Hygiene

Managing Health Care

Securing Health Care

Turning and positioning in bed/chair

Adult diapers / liners

Instrumental Activities of Daily Living

Doing laundry

Shopping

Securing and using transportation

Managing finances

Using the telephone

Making and keeping appointments

Caring for personal possessions

Written correspondence

Engaging in social and leisure activities

Using a prosthetic device

Uses wheelchair

Uses walker

Uses cane

Hearing

Total hearing impairment

Hears with device

Vision

Total visual impairment

Sees with device

History of Problematic Behavior (Check all that apply):

Suicide attempts

Fire-starting

Physical violence toward others

Sexually abusive or inappropriate acts

Substance abuse

Behaviors Exhibited (Check all that Apply)

Anxiety

Physically violent

Disorientation

Delusional

Agitation

Lethargy

Hostility

Wandering

Confusion

Hallucinations

Sadness

Requires secured care due to Alzheimer's Disease or other dementia