Virtual Needs Assessment

Employee Name*
First Last
Name of Loved One (client)*
Prefix First Middle Last Suffix
Relationship to client*
- Spouse/Partner
- Parent of Child
- Adult Child
Email*
Phone*
Medical:
Has your loved one been diagnosed with more than one chronic condition?*
- Yes
- No
- Unsure
Please choose the chronic condition(s) your loved one has.*
- Diabetes
- Memory Loss/Dementia/Alzheimer's
- Heart Disease/Congestive Heart Failure (CHF)
- Stroke
- Neurodegenerative Diseases (Parkinson, ALS, MS, etc)
- Chronic Obstructive Pulmonary Disease (COPD)
- Traumatic Brain Injury (TBI)
- Cancer
- Behavioral Health-bipolar, depression, schizophrenia, etc.
- Autism/Down's Syndrome
- N/A
Does your loved one display signs of cognitive decline? (i.e. dementia, forgetfulness, depression, anger)*
- Yes
- No
- Unsure
Do you have concerns with your loved one being able to independently manage the activities of daily life? (i.e. bathing, dressing, eating, walking, sleeping, toileting)*
- Yes
- No
- Unsure
Is your loved one currently taking more than 3 medications? (prescriptions or over-the-counter)*
- Yes
- No
- Unsure
Have you noticed any major health changes in your loved one in the last 6 months?*
- Yes
- No
- Unsure
Are health issues your primary concern*
- Yes
- No
Environmental
Where is your loved one living or residing at the current time?*
- Home
- Hospital
- Rehabilitation unit -3 hours of therapy (hospital based)
- Skilled nursing rehab (nursing home) (short stay)
- Nursing Home (long term)
- Assisted Living
- Memory Care
- Retirement Community
Does your loved one currently live at home alone?*
- Yes
- No
- N/A
Do you have questions or concerns about home safety modifications where you loved one is living? (i.e. wheelchair access, grab bars in bathing or dressing areas)*
- Yes
- No
Do you have concerns with your loved one driving?*
- Yes
- No
Is your loved one unable to obtain on-demand transportation?*
- Yes
- No
Do you feel your loved one is safe in their current environment?*
- Yes
- No
Are environmental issues your primary concern?*
- Yes
- No
Psychosocial
Do you have concerns for your loved one regarding socialization or isolation?*
- Yes
- No
Does your loved one lack support from family or friends nearby?*
- Yes
- No
Has your loved one stopped attending out of home functions? (i.e. church, clubs, friends’ gatherings, etc.)*
- Yes
- No
Do you have any concerns about anyone in your loved one’s life having undue influence?*
- Yes
- No
Do you have concerns for your loved one regarding family or friend dynamics?*
- Yes
- No
Are behavior issues your primary concern?*
- Yes
- No
Financial
Do you have concerns over your loved one’s cost of care?*
- Yes
- No
Check all the financial benefits that you know your loved one has:*
- Medicare
- Medicaid
- Medicare Advantage
- Social Security - Retirement (SSI)
- Social Security Disability (SSDI)
- Pension
- VA
- Unknown
Do you have questions about accessing available or understanding healthcare benefits for your loved one? (i.e. Medicare, VA benefits, retiree plan)*
- Yes
- No
Do you have a need or interest in creating a planned budget for costs of care?*
- Yes
- No
Are you interested in other benefit programs available to your loved one?*
- Yes
- No
Are your loved one’s finances your primary concern?*
- Yes
- No
Legal:
Do you have your loved one’s legal documents or lack thereof?*
- Medical Power of Attorney
- Durable Power of Attorney
- Advanced Directive
- Do Not Know
Do you know who the are the designees for your loved one’s Medical or Durable Power of Attorney?*
- Yes
- No
Do you have questions about your loved one’s mental ability or memory?*
- Yes
- No
Has your loved one been exposed/had increased exposure to financial predators?*
- Yes
- No
Have you considered obtaining assistance with legal care planning for your loved one?*
- Yes
- No
Does your loved one have any existing fiduciary relationships? (i.e. trustee, wealth manager, CPA)*
- Yes
- No
Are legal issues your primary concern for your loved one?*
- Yes
- No
Please describe the one issue you feel needs to be address immediately:*
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Virtual Needs Assessment

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Environmental

Psychosocial

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