START YOUR NEW CLIENT NEEDS ASSESSMENT

This form takes 10-15 minutes to complete, and it speeds up the process for your FREE consultation.

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CLIENT PROFILE INFORMATION - Step 1 of 6

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Date

Referred by

How did you hear about Senior Care Lifestyles

Inquirer Details

Name of Inquirer *

First

Last

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Inquirer's Phone Number *

Inquirer's Email *

Inquirer's Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Inquirer's Relationship to Senior *

Senior's Details

Senior's Name *

First

Last

Age *

Gender *

Male
Female

Sexual Orientation/Identity

Gay
Lesbian
Straight
Bisexual
Asexual

DEFINITION: Sexual orientation is about who you’re attracted to and who you feel drawn to romantically, emotionally, and sexually. It’s different than gender identity. Gender identity isn’t about who you’re attracted to, but about who you ARE — male, female, genderqueer, etc. This means that being transgender (feeling like your assigned sex is very different from the gender you identify with) isn’t the same thing as being gay, lesbian, or bisexual. Sexual orientation is about who you want to be with. Gender identity is about who you are.

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Senior's Height

Is there a Power of Attorney for Finances? If yes, who?

Senior's Weight

Is there a Power of Attorney for Healthcare: If yes, who?

Seniors Address (If resides in own home)

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

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Ethnicity

Religion

Habitual Tendencies

Alcohol
Drugs
Smokes (include medicinal)

Habitual Tendencies Comments / Details

Senior’s Previous Occupation

Senior’s Likes/Dislikes/interests

Senior Housing Type Desired

Zip Codes requesting placement in:

Time Frame to Move:

Current Living Situation

Name of Hospital / Rehab (if applicable):

What was the admission date?

Do you have a discharge date?

Discharge Date:

Room #:

Name of Assigned Social Worker / Case Manager:

First

Last

Social Worker / Case Manager's Phone:

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This section helps us determine all the sources of income and potential income; i.e. sale of home, property…that may contribute toward determining the Monthly Budget for the seniors care costs. The monthly budget that the family agrees upon dictates the senior living communities we can discuss with you and tour. We will never ask for account numbers or financial details so we trust you, our client, to provide approximate sources of income as accurately as possible. Please put N/A in any fields that do not apply.

Total NET Monthly Budget (after mandatory expenses; i.e. Medicare supplemental insurance, Rx, cell phone) *

Monthly NET Social Security

Please put N/A in fields that do not apply.

Monthly NET Pension

Please put N/A in fields that do not apply.

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Checking Account $ (Approximately)

Savings Account $ ( Approximately)

Is Senior a Veteran or Spouse of Veteran

If yes, has the Senior Applied for the VA Aid & Attendance Benefit?

If yes, date applied:

Is the Senior receiving the VA Aid & Attendance Benefit?

If yes, what is the monthly amount

Please put N/A in fields that do not apply.

Do you have the Senior’s DD214 Discharge Papers?

Does the Senior have a Long Term Care (LTC) Policy

If yes, how much?

Name of LTC Company (leave blank if you do not know )

LTC Policy Elimination Period (This is the # days before you start receiving payments, typically 60-90 days)

Other Income Assets

Real Estate Properties

Are you planning to use the proceeds of the sale of a home or property toward care costs?

If so, what is the approximate value of the home?

Is there a mortgage remaining?

If yes, what amount?

Reverse Mortgage?

If yes, what amount? (copy)

Equity Line of Credit?

If yes, what amount?

Do you need assistance selling the home and/or recommendations for local realtors to contact?

Other Assets for care costs consideration

This information is also used toward determining the seniors monthly budget. The monthly budget dictates the senior living communities we can discuss with you and tour. We will never ask for account numbers or financial details, so we trust you, our client, to provide approximate sources of income as accurately as possible.

401K

Amount of 401K

Annuities

Amount of Annuity

Insurance Policies

Type of Policies

Comments

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Check all Chronic Illness(s):

Arthritis
Cancer
COPD
Oxygen Dependent
CPAP / BiPAP machine
Osteoporosis
Diabetic
Heart Disease
Hearing Impairments
High Blood Pressure
Stroke
Rheumatoid
Visual Impairments
Urinary Incontinence
Catheter
Congestive Heart Failure
None
Other

Comments:

Approximate # of Medications per day:

List Medications (if possible)

Medication Allergies?

If yes, please provide details (include any allergic prescription and over the counter):

If diabetic, how is it treated?

Diet only
Pills
Regular Insulin
Sliding Scale Insulin

Does the Senior have any open wounds or rashes?

If yes, how long has the wound been present?

If yes, how is the wound / rash being treated?

If yes, what is the frequency of treatment?

If yes, does the wound /rash affect activities of daily living (walking, sitting, laying down, etc.)

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

Difficulty Swallowing

Known Food Allergies/Intolerances

If YES please list all foods and describe allergic reaction symptoms:

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

Additional Comments:

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Has Senior been diagnosed with Dementia?

Date of Diagnosis:

If yes, what kind?

Alzheimer's disease
Vascular dementia
Dementia with Lewy bodies
Parkinson's disease
Frontotemporal dementia
Huntington’s Disease
Creutzfeldt-Jakob Disease
Normal Pressure Hydrocephalus
Posterior Cortical Atrophy
Korsakoff Syndrome
Early On-set Dementia
Other

Comments:

Does the senior have Aphasia? The inability to understand or use language? Familiar objects? (Retention of information over weeks to months, remembers family names)

Short term memory loss (Retention of information over a span of a few minutes to a few hours)

Long term memory loss (Retention of information over weeks to months, remembers family names)

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Mobility

Cane
Walker
Wheelchair
Independent - No assist
With Supervision, or Stand-by
One-person physical assistance
Two-person, Full assistance, Hoyer lift
Bed Bound

If yes to wheel chair

Can transfer self to/from Bed (no assistance)
Can transfer self to/from toilet
Is a 1 person assist
Is a 2 person assist

Fall Risk

Mobility Comments

Needs Ambulation Assistance (Transfers to/from)

If yes, what kind?

Needs minimal assistance
Able to self-pivot
1 person assist to/from bed to Wheel Chair / Walker / Chair
2 person assist to/from toilet to Wheel Chair / Walker / Chair

Ambulance Comments

Use of Stairs

Independent
With Supervision
One-person Physical Assistance
Needs Stair Glide

Use of Stairs Comments

Continence/Toileting (Select all that apply)

Independent – No assistance
Reminders - Needs a Scheduled Toileting Program
Supervision / Minimal Assist
Needs Physical Assistance To & From Toilet
Needs Personal Hygiene Cleaning Assistance
Needs Full Assistance with Bed Pan

Fall Risk?

Mobility Comments

Bathing

Independent
With Supervision/Stand By
Needs Physical Assistance In & Out of Tub
Complete Assistance/Hoyer List

Bathing Comments

Grooming

Independent
With Supervision
Needs Physical Assistance

Grooming Comments

Dressing

Independent
With Supervision
Needs Physical Assistance

Dressing Comments:

Eating

Independent
Needs food cut
Needs assistance with utensils
Needs total assistance

Select all that apply

Drinking

Independent
Needs Assistance holding cup
Cannot hold cup
Needs straw to drink

Select all that apply

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1) Withdrawn / Keeps to themselves

Yes
No
Sometimes

2) Depressed

Yes
No
Sometimes

3) Wanders

Moving without purpose

Yes
No
Sometimes

Looks for former home

Yes
No
Sometimes

Actively tries to leave home

Yes
No
Sometimes

Wanders during day

Yes
No
Sometimes

Wanders during evening/night:

Yes
No
Sometimes

Comments about wandering

4) Sleep Disturbance

Unable to sleep/agitated at night

Yes
No
Sometimes

Frequently sleeps during the day

Yes
No
Sometimes

Comments about sleep

5) Verbally Inappropriate

Uses foul language

Yes
No
Sometimes

Sounds angry and threatening

Yes
No
Sometimes

Comments about Verbally Inappropriate

6) Disruptive Behaviors

Yells

Yes
No
Sometimes

Demands Attention

Yes
No
Sometimes

Takes others possessions

Yes
No
Sometimes

Inappropriate Public Behavior (Disrobes/Urinates)

Yes
No
Sometimes

Comments about Disruptive Behaviors

7) Combative Behaviors

Throws objects

Yes
No
Sometimes

Strikes out, Kicks or Punches

Yes
No
Sometimes

Pinches, bites, spits, scratches, pulls hair

Yes
No
Sometimes

Comments about Combative Behaviors

8) Resistant Behaviors

Refuses to wash

Yes
No
Sometimes

Refuses to eat

Yes
No
Sometimes

Refuses to drink

Yes
No
Sometimes

Refuses to care for self

Yes
No
Sometimes

Refuses to allow others to help

Yes
No
Sometimes

Refuses Medicines

Yes
No
Sometimes

Comments about Resistant Behaviors

9) Communication

Expresses needs, ideas, wants

Yes
No
Sometimes

Unwilling to communicate needs

Yes
No
Sometimes

Unable to communicate

Yes
No
Sometimes

Comments about Communication

10) Eating patterns

Eats full scheduled Meals / good appetite

Yes
No
Sometimes

Eats sometimes, but still maintains weight

Yes
No
Sometimes

Eats only when they want

Yes
No
Sometimes

Comments about Eating

Have you called other placement services or submitted on-line requests for information?

Who?

Have you contacted or toured any communities?

Where?

Upload any related documents:

Click or drag a file to this area to upload.

Comments

Important!

Please make sure all fields with an asterisk* in Section 1 are filled before submitting. You will receive an email acknowledging that your Needs Assessment was received. Thank you!

Senior Care Lifestyles, LLC is the sole owner of the information collected on this site. We will not sell this information, or share this information with any third party entity. This information is considered confidential and is used in the search for communities and senior housing options that meet the client’s medical needs, personal care, and budget.

All information provided is optional and confidential. Senior Care Lifestyles will NOT share your information with any other parties without prior discussion and approval from our clients.

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All information provided is optional and confidential. Senior Care Lifestyles will NOT share your information with any other parties without prior discussion and approval from our clients.