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Help us to understand your needs

  • Needs Assessment Form

    General Questions Section1

    Help us to understand your needs

  • Registrant Photo

  • Contact Phone #

  • Who is been assessed?

  • I am completing this for.

  • Contact Phone #

  • Sexual orientation is about who you want to be with. Gender identity is about who you are.

  • Please select all that apply

  • what is your ethnic identity

  • Do you have a religious preference? Please explain in your notes section

  • Other information we need to know about including habitual tendencies. Alcohol/ Smoking/ Use of unprescribed drugs or medication.

  • Section 2 HEALTH

  • Do you have any Long-Term Care policies?

  • Have you ever had or have any of the following conditions?

  • Medication

  • Dietary Restrictions (soft foods, meats, mechanical diet, liquids, etc.):

  • Environmental Allergies (animals, birds, plants, flowers, scents, cleaning products, lotions, etc.:

  • SECTION 3 ACTIVITIES OF DAILY LIVING (ADL)

  • The ability to move or be moved freely and easily.

  • I need assistance

  • SECTION 4 FINANCE

  • What kind of employment

  • What king of housing would you prefer?

  • Who will make payments for you?

  • Payment Source

  • Strength Indicator
  • Assessment Date

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