Caring Hands For Abilities – Comprehensive Client Needs Assessment

Caring Hands For Abilities – Comprehensive Client Needs Assessment

Supporting abilities. Preserving dignity. Strengthening families.
This comprehensive assessment helps Caring Hands For Abilities understand the individual’s full care needs, preferences, and safety considerations. Information shared here allows us to develop appropriate care recommendations. This form is provided as a private link following initial screening.
Applicant & Client Information

Please provide information about yourself and the individual seeking care.
Applicant Full Name

First NameLast Name
Client Full Name

First NameLast Name
Relationship to Client
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Client Date of Birth

MonthDayYear
Date
Client Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Medical & Health Overview

Share information about the client’s medical background and health needs.
Primary Diagnosis or Disability
Secondary Conditions
Primary Physician Name and Phone
Current Medications (list)
Allergies
Recent Hospitalizations or Discharges (past 12 months)
Supporting Documents (doctor’s notes, discharge summaries, care plans, therapy notes)

Cancelof
Functional Abilities & Daily Living Support

Tell us about the client’s abilities and support needs for daily living.
Assistance Needed with Activities of Daily Living (ADLs)

Other
Assistance Needed with Instrumental Activities of Daily Living (IADLs)

Other
Mobility Status
Assistive Devices or Medical Equipment Used
Cognitive, Behavioral & Emotional Support

Describe any cognitive, behavioral, or emotional support needs.
Cognitive Status
Behavioral or Emotional Support Needs
Communication Considerations
Care Preferences & Schedule

Help us understand your care preferences and scheduling needs.
Type of Care Requested

Other
Preferred Days and Times
Estimated Hours per Week
Preferred Start Date

MonthDayYear
Date
Care Location
Cultural, Religious, or Personal Preferences
Safety & Risk Assessment

Share any safety concerns or risks to help us plan appropriately.
History of Falls
Seizures or Medical Emergencies
Wandering Risk
Safety Concerns in the Home
Emergency Contact Name

First NameLast Name
Emergency Contact Relationship
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Insurance & Care Coordination

Provide insurance or funding details and care coordination contacts.
Insurance or Funding Source
Medicaid/Waiver ID (if applicable)
Case Manager or Service Coordinator Name and Contact
Additional Information

Is there anything else our care team should know?
Anything Else the Care Team Should Know
Authorization & Signature

Please review and sign to authorize Caring Hands For Abilities to review this information for care planning.
Applicant Electronic Signature
Signature Date

MonthDayYear
Date
Should be Empty:

Caring Hands For Abilities – Comprehensive Client Needs Assessment

Applicant & Client Information

Medical & Health Overview

Functional Abilities & Daily Living Support

Cognitive, Behavioral & Emotional Support

Care Preferences & Schedule

Safety & Risk Assessment

Insurance & Care Coordination

Additional Information

Authorization & Signature