Care and Support Assessment Form
A little information will help me understand where you need support. Whether you're completing this form for yourself or for someone you care about, I'd like to understand what's working, what's becoming difficult, and which responsibilities are taking the most time and energy. There is no right or wrong answer. You don't need to know exactly what kind of help you need — that's part of what I can help you figure out.
Who is completing this form?
I am the person who needs care/support
I am a spouse/partner helping someone I care about
I am an adult child helping a parent
I am another family member
I am a friend, neighbor, or other support person
Full Name
*
First Name
Last Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Who are you seeking support for?
Myself
Someone else
Name of person needing support
First Name
Last Name
Where does this person currently live?
In their own home
With a family member
Assisted living
What are the biggest challenges you are facing right now? Check as many as applicable.
Managing health conditions
Mobility or physical limitations
Memory or cognitive changes
Medication management
Getting to appointments
Managing household responsibilities
Meals and nutrition
Transportation
Running errands
Finding or coordinating caregivers
Financial/resource planning
Insurance or benefits
Making decisions about future care
Preparing for a move or transition
Feeling overwhelmed by everything that needs to be managed
Family conflict
Other
Please describe "other"
Are there specific health conditions, ailments, or concerns you'd like me to understand?
Which responsibilities are currently taking the MOST time or creating the MOST stress?
Transportation coordination
Doctor/medical appointments
Accompanying someone to appointments
Scheduling appointments
Medication management
Grocery shopping
Meal planning and prep
Making sure meals are being eaten
Running errands
Household organization
Cleaning/laundry
Personal care
Mobility assistance
Finding caregivers
Managing in-home caregivers
Coordinating family members
Paperwork
Bills/financial organization
Insurance/benefits
Finding community resources
Researching care options
Planning for future care
Downsizing/moving
Home organization
Keeping track of everything
Other
Please describe "other"
If you could have 3 responsibilities taken off your plate right now from the list above, what would they be?
What kind of help would make day-to-day life easier?
Transportation/driving
Errands
Meal prep
Appointment scheduling
Appointment accompaniment
Household organization
Caregiver coordination
Companionship/social engagement
Physical exercise support
Help researching options
Help organizing information
Other
Please describe "other"
How often is support needed?
Occasionally
Once or twice a week
Several times a week
Daily
Would help with the financial/resource side of care be valuable?
Yes
Maybe — I'm not sure what resources are available
No
What would you like help with?
Understanding potential care costs
Planning for future care
Finding available resources
Exploring benefits/programs
Comparing care options
Understanding in-home care options
Understanding assisted living/memory care options
Organizing care-related expenses
Creating a plan based on available resources
I don't know where to start
What is your biggest concern about paying for or planning for care?
What would make the biggest difference in your life right now?
If you had more time and support, what would you rather be spending your time doing?
Is there anything else you'd like me to know about your situation?
Preferred way to connect:
Phone
Email
Video Call
You're not expected to figure it all out yourself! Whether you're navigating care for yourself or trying to help someone you love, you don't have to have all the answers before reaching out.
My job is to help you identify what is taking up your time, where the biggest challenges are, and what support or resources could make things easier.
Submit Assessment
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