T.N.T. Adult Family Care Home LLC
Caring with compasssion and Dignity
1. Client Information
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Date of Assessment
-
Month
-
Day
Year
Date
Assessed By
Gender
Please Select
Male
Female
Other
Prefer not to say
Medicaid / Medicare ID
Social Security # (Last 4 Digits)
Current Address
2. Referral Information
Referral Source
Caseworker Name
Caseworker Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Caseworker Email
example@example.com
3. Presenting Needs
Reason for Placement
Describe the primary reason the resident is seeking placement at T.N.T Adult Family Care Home
Immediate Needs (Select all that apply)
Housing / placement
Medication monitoring
Nutritional support
Assisted daily living (ADL)
Medical support
Mental health support
Transportation
Family / social support
Other
Requested Admission Date
-
Month
-
Day
Year
Date
Care Type
Please Select
Short-term
Long-term
Respite
Other
4. Mental & Emotional Status
Current Mental Health Status
Stable
Unstable
Unknown
History of Mental Health Diagnosis?
Yes
No
Currently Receiving Treatment?
Yes
No
IF YES, Specify Diagnosis / Treatment Details
5. Physical Health Status
Overall Physical Health Condition
Good
Fair
Poor
Mobility Issues?
Yes
No
Requires Medical Assistance?
Yes
No
Incontinence?
Yes
No
Primary Diagnoses / Conditions
Allergies
Current Medications
Primary Care Physician
Physician Phone
Please enter a valid phone number.
Format: (000) 000-0000.
6. Daily Living Skills (ADLs)
Ability to Perform Daily Tasks
Independent
Minimal Support
Moderate Support
Full Assistance
Areas of Support Needed (Select all that apply)
Hygiene / grooming
Dressing
Bathing
Cooking / Meal Prep
Medication Management
Transportation
Housekeeping
Financial Management
Mobility / transferring
Other
7. Behavioral Assessment
History of Aggression or Violence?
Yes
No
Any Behavioral Concerns?
Yes
No
Additional Behavioral Notes
8. Housing History
Previous Living Situation
Number of Prior Placements
History of Homelessness?
Yes
No
9. Risk Assessment
Risk Level
Low
Medium
High
Any Safety Concerns?
Yes
No
DNR / Advance Directive on File?
Yes
No
IF SAFETY CONCERNS, EXPLAIN
10. Support System
Family Support Available?
Yes
No
Community Support?
Yes
No
Active Case Management?
Yes
No
Emergency Contact Name
Relationship to Resident
Emergency Contact Phone (Primary)
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Phone (Alternate)
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Email
example@example.com
11. Financial & Insurance
Payment Method
Private Pay
Medicaid
Medicare
Other
Insurance Provider
Policy / Member ID
Group Number
12. Recommendation
Recommended Level of Support
Low
Moderate
High
Additional Recommendations / Notes
Assessor Signature
Assessor Printed Name
Assessment Date (Signature Section)
-
Month
-
Day
Year
Date
Assessor Signature
Submit Assessment
Submit Assessment
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