Free Care Assessment

1

Get Connected With Local Agencies

What Is Your Name?

What Is The Zip Code Address For The Place Of Care?

Please Enter The Email You Would Like To Receive Your Local Agencies Suggestions To

Please Enter Your Contact Phone Number

2

Who are you seeking care for?* This field is required.

3

Select which best describes their mobility?

Independent with no difficulty moving around.

Needs occasional mobility assistance but can manage most tasks alone.

Needs constant assistance or uses a mobility aid (walker, wheelchair).

Immobile, Bed bound.

4

What best describes their ability to perform activities of daily living?Bathing, Dressing and Grooming

Unable to stay clean and groomed without help from others.

Requires significant help or supervision to stay clean and groomed.

Needs occasional reminders or assistance to stay clean and groomed.

Independent, with no difficulty staying clean and groomed.

5

Does your loved one take medication?* This field is required.

YESNO

6

How is your loved one managing their medications?

Manages their own medications without support.

Requires daily reminders to take their medications correctly.

Needs occasional reminders to take medication.

Unable to manage their medications without support.

7

How are they managing medical appointments

Needs no assistance to make or attend appointments.

Needs occasional reminders about upcoming appointments/travel arrangements

Requires full assistance to make and attend appointments

9

How often do they experience memory loss or confusion?

Never

Rarely

Sometimes

Constantly

10

Describe your loved one's social life?

Regularly engages with friends or family.

Occasionally engages with friends or family, but would benefit from more.

Often feels isolated

Almost no social interaction and feels very isolated.