Virtual Needs Assessment Virtual Needs Assessment Employee Name* First Last Name of Loved One (client)* Mr.Mrs.MissMs.Dr.Prof.Rev. 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 EnvironmentalWhere 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 PsychosocialDo 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 FinancialDo 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:*CAPTCHA Δ
