Transportation

Client's Initials
GOVERNOR'S OFFICE OF ELDERLY AFFAIRS
Louisiana Independent Living Assessment (LILA) Statewide Comprehensive Needs Short Assessment Form
Assessment Date

MonthDayYear
Date
Re Assessment Date

MonthDayYear
Date
Are you a Veteran

YesNo
Veteran Dependent

YesNo
Does The Client Wish to be evacuated in case of a disaster

YesNo
(Should be in different color ink)
First Name
Last Name
Client Suffix
Client Maiden Name
Client AKA Name
Marital Status:

DivorcedSeparatedMarriedSingleWidowed
Age
Gender

MaleFemale
Date of Birth

MonthDayYear
Date
COA Membership Card Declined Accepted
Accepted
Declined
Last 4 of Client's SS #: Client's ID:
Last 4 of Client's SS #
Client's ID
Home Phone Number
Cell Number
Client's Mailing Address (if same write SAME):
Street
P.O. Box,
Town
Town
State
Zip Code
State
Zip Code
Other (Individual $12,060 EY 2017) Monthly Poverty Guideline per Person: Monthly 1-$1,005 or less 4-$2,050 or less Income: 2-$1,353 or less 5-$2,398 or less 3-$1,702 or less 6-$2,747 or less

Monthly HouseholdIndividual Income:
Monthly House Hold Income
Monthly Individual Income
Insurance Medicaid:

YesNo
House Hold Size
Medicaid Policy #
Medicare #
Medical Assistance ID #
Client's Initials
Ethnicity

Hispanic/LatinoNot Hispanic/ LatinoUnknown
High Nutritional Risk :

YesNoDon't Know
In Poverty:

YesNoDon't Know
Lives Alone

YesNoDon't Know
Is Rural

YesNoDon't Know
NSIP Meal Eligible:

YesNo
From Page 4. Nutritional Score
Eligibility Type: Age 60 or over Disabled in Elderly Housing Disabled living with Elderly Person

Food Handler Guest/Staff under 60 I&R Client Not Indicated Other

Spouse Tribal Age Specification

Duplicate Mail: Abuse/Neglected/Exploited: (Everyone in household gets same piece of mail) Yes No

Cognitive Impairment: Early Onset Dementia Mild Moderate

Declined to state Full Time None Part Time Retired
Abuse/ Neglected/ Exploited

YesNo
Cognitive Impairment:

Early Onset DementiaMildModerateNoneSevereNone
Disabled:

YesNo
Frail

YesNo
Homebound

YesNo
Duplicate Mail

YesNo
Female Head of House Hold

yesNo
Medicare Eligible:

YesNo
State Resident

YesNo
Tribal

YesNo
Understand English:

YesNo
U S Citizen

yesNo
Employment Status

Declined to stateFull TimeNonePart timeRetiredUnemployedUnknown
Receiving Social Security

YesNo
Languages

EnglishSpanishFrenchItalianRussianGermanOther
Race

American Indian/Alaskan NativeAsianBlack/ African AmericanNative Hawaiian / Other Pacific IslanderWhite (non-Minority/ non - Hispanic)White HispanicOther
American Indian/Alaska Native Asian Black/African American Native Hawaiian/Other Pacific Islander

White (Non-Minority/Non-Hispanic) White Hispanic
Client's Initials
Emergency Contact: Primary Physician
Name
Relative/ Friend: (other than Spouse/Partner not living in the household to contact in case of emergency)
Address
Name
Address
Phone
Phone
Cell
Relationship
Directions to Client's Home
Acknowledgement Do you have prescription drug insurance?
Yes
No
Client has been advised that he/she has an opportunity to make voluntary and anonymous donations for any service they may receive and has received a copy of policy.

Refer client to SenioRx for prescription assistance.
Yes
No
The client formally authorized release of information. Copy of signed and dated authorization is attached to this
Where did assessment take place
Client Signature

Clear
Date

MonthDayYear
Date
No
Yes
List services the client will receive
Assessor's Signature

Clear
Date

MonthDayYear
Date
RE-ASSESSMENTS must be completed in a different color ink.
Where did re assessment take place
Client Signature

Clear
Date

MonthDayYear
Date
Assessor Signature

Clear
Date

MonthDayYear
Date
Client's Initials
Nutritional Health Risk (Circle your answers and add up your score) Has the client made any changes in lifelong eating habits because of health problems? Does the client eat fewer than two meals per day? Does the client eat fewer than five servings (1/2 cup each) of fruits and vegetables? Does the client eat fewer than two servings of dairy products (such as milk, yogurt, or cheese) every day? Does the client sometimes not have enough money to buy food? Does the client have biting, chewing. or swallowing problems that makes it difficult to eat? Does the client eat alone most of the time? Without wanting to, has the client lost or gained ten pounds in the past six months? Is the client physically able to shop, cook, and/or feed themselves (or to get someone to do it for them)? Does the client have three (3) or more drinks of beer, liquor. or wine almost every day? Does the client take three (3) or more different prescriptions or over-the-counter drugs per day?
TOTALS
Add YES + NO for your total nutrition score. If score is: 0-2 GOODI Recheck the Nutritional Score in 6 months. 3 5 You are at moderate nutritional risk. See what can be done to improve your eating habits and lifestyles. Your area agency on aging, senior nutrition program, senior citizens center or health department can help. Recheck your Nutritional Score in 3 mo. 6 or moreYou are at high nutritional risk. Bring a copy of this checklist the next time you see your doctor, dietitian, or other qualified health or social service professional. Talk with them about any problems you may have. Ask for help to improve your nutritional health. (Be sure to put score total on second page of assessment)
COMBINED TOTAL
Client's Initials
MEDICATION REVIEW
A. MEDICATION USE: (Ask the client if you can see the medications so that you can verify frequency, dosage, etc. Include over the counter drugs like aspirin, laxatives, and vitamins. Some medicines may be refrigerated 1. Are you taking any medicines? If so, could you show them to me so we can list their names and dosage?
Medication Name blanks Primary Diagnosis blank Strength/ Direction Type a label Prescribing Doctor/ Phone Type a label Manufacture Type a label
Medication Name blanks Primary Diagnosis blank Strength/ Direction Type a label Prescribing Doctor/ Phone Type a label Manufacture Type a label
Medication Name blanks Primary Diagnosis blank Strength/ Direction Type a label Prescribing Doctor/ Phone Type a label Manufacture Type a label
Medication Name blanks Primary Diagnosis blank Strength/ Direction Type a label Prescribing Doctor/ Phone Type a label Manufacture Type a label
Medication Name blanks Primary Diagnosis blank Strength/ Direction Type a label Prescribing Doctor/ Phone Type a label Manufacture Type a label
Medication Name blanks Primary Diagnosis blank Strength/ Direction Type a label Prescribing Doctor/ Phone Type a label Manufacture Type a label
Medication Name blanks Primary Diagnosis blank Strength/ Direction Type a label Prescribing Doctor/ Phone Type a label Manufacture Type a label
No Yes b. 2. Do you have problems or difficulty remembering to take your medications? a. (If necessary, prompt the client by asking if s/he is concerned about forgetting. What steps does s/he take to remember?)
Yes
No
3. Please list your drug allergies
4. Referral made
Rapides Council on Aging, Inc. "Serviga the Elderly 1967*
Date

MonthDayYear
Date
Name & Address
Acknowledge that I have received a Grievance Form for the Following Programs.

MealsChoreTransportationTelephoneRespiteOutreach
Acknowledge that I have received a Grievance Form for the

(Circle all that apply) Programs.
SIGNATURE

Clear
COUNCIL STAFF
(318)445-7985 An Equal Opportunity Employer
Rapides Council on Aging, Inc. the Elderly 1967*

Tamechia Beemon Executive Director

Andrea Cobb Asst. Executive Director/

Authorize the release of information contained in the Louisiana Assessment (LILA) form to other agencies or entities to determine eligibility for services.

Donna Fontenot Program Manager

Linda Gates Outreach Specialist/ Reception
Name

First NameLast Name
Signed

Clear
Date

MonthDayYear
Date
Barbara Young Outreach Specialist/ Data Entry
Witness
Rita Young Outreach Specialist/ Chore Program
Transportation/Malntenance Supervisor

(318)445-7985 An Equal Opportunity Employer
COMMUNICATIONS WITH CAREGIVERS AND RELATIVES We may use or disclose your information tonotify or assist in notifying: (1) a family member, personal representative, or caregiver regarding your location and general condition; (2) a family member, other relative, close personal friend, or any other person you authorize, as necessary for and directly relevant to that person's involvement in your care. Please assign an authorized person here: Name: Phone Number
Name
When GOEA, Area Agencies on Aging, and Councils on Aging may not use or disclose your health information: Except as described in this Notice, we will not use or disclose your health information without your written authorization. If you do authorize use or disclosure of your health information for another purpose, you may revoke your authorization we must follow state law.in writing at any time. if Louisiana law provides additional restrictions upon any of the foregoing uses and disclosures, You have the following rights with respect to your health information: -You have the right to request restrictions on certain uses and disclosures of your health information. We are not required to agree to a restriction that you request. We cannot agree to limit the uses or disclosures of information that are required -You have the right to inspect and copy your health information as long as we maintain the health information. Simply submit a written request to us. We may charge you a fee for the costs of copying, mailing or other supplies that are needed to grant your request. We may deny your request in certain limited circumstances. -You have the right to request that we amend your health information that is incorrect or incomplete. To request an amendment, submit a written request to the servicing agency, along with the reason for the request. We are not required to amend health information that is already accurate and complete. -You have a right to receive an accounting of disclosures of your health information we have made for purposes other than disclosures (1) you have requested or authorized, and (2) for certain government functions. To request an accounting, you must submit a written request that specifies the time period you choose. -You may request communications of your health information by alternative means or at alternative locations. For example, you may request that we contact you about health matters only in writing or at a different residence or post office box. To request confidential communication of your health information, you must submit a written request to the will accommodate all reasonable requests.Council on Aging location providing services. Your request must state how or when you would like to be contacted. We

For more information or to report a problem: If you have questions or would like additional information about our privacy practices. you may contact the Louisiana Governor's Office of Elderly Affairs at PO Box 61 Baton Rouge LA 70821-006 or 225.342.7100. If you believe your privacy rights have been violated, you can file a complaint with the Office of Elderly Affairs at the above address. There will be no retaliation for filing a complaint.

I have received a copy of the GOEA Privacy Notice:
Client Signature

Clear
Date

MonthDayYear
Date
Rapides Council on Aging 204 Chester Street Alexandria, LA 71301 (318) 445-7985
CLIENT SERVICE LOG
NAME
ID#
DOB
AGE
ELIGBLE: YES
ASSESSMENT DATE

MonthDayYear
Date
RE ASSESSMENT DATE

MonthDayYear
Date
LIST SERVICES CLIENT IS ELIGIBLE FOR AND BEGIN/END DATE
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
LIST SERVICE PENDING WAITING LIST
SPECIAL NEEDS
COMMENTS
Should be Empty:

GOVERNOR'S OFFICE OF ELDERLY AFFAIRS

MEDICATION REVIEW

CLIENT SERVICE LOG

ELIGBLE: YES

LIST SERVICES CLIENT IS ELIGIBLE FOR AND BEGIN/END DATE

LIST SERVICE PENDING WAITING LIST