Planning Checklist for Caregiving Families Part 3

General Needs Assessment Home Maintenance and Living Situation ____ Pay rent/mortgage ____ Home repairs ____ Ongoing maintenance ____ Safety concerns ____ Accessibility for disabilities ____ Grocery shopping & meal preparation ____ Lawn care ____ Pet care ____ Housekeeping ____ Other: ________________________ APPOINTED FAMILY MEMBER: ADDRESS: PHONE: EMAIL: APPOINTED FAMILY MEMBER: ADDRESS: PHONE: EMAIL: Financial Affairs ____ Paying bills ____ Keeping track of financial records ____ Supervising public benefits programs, etc. APPOINTED FAMILY MEMBER: ADDRESS: PHONE: EMAIL: Transportation Needs ____ Driving decisions ____ Coordinating rides APPOINTED FAMILY MEMBER: ADDRESS: PHONE: EMAIL: Perso

Planning Checklist for Caregiving Families Part 2

Home Safety Steps, Stairways, and Walkways Yes No ❑ ❑ Are they in good shape? ❑ ❑ Do they have a smooth, safe surface? ❑ ❑ Are there handrails on both sides of the stairway? ❑ ❑ Are there light switches at the top and bottom of the stairs? ❑ ❑ Is there grasping space for both knuckles and fingers on railings? ❑ ❑ Are the stair treads deep enough for your whole foot? ❑ ❑ Would a ramp be feasible in any of these areas if it became necessary? Floor Surfaces Yes No ❑ ❑ Is the surface safe? ❑ ❑ Is the surface nonslip? ❑ ❑ Are there any throw rugs or doormats that might slip underfoot? ❑ ❑ Is carpeting loose or torn? ❑ ❑ Are there changes in floor levels? ❑ ❑ If so, are they obvious or well marked

Planning Checklist for Caregiving Families Part 1

Personal History Name (First Middle Last): Name at birth (First Middle Last): Place of birth (City State Country): Date of birth: Date of adoption: Legal name change (First Middle Last): Legal name change date: Legal name change court: Court City State: Current address: # of years: Phone: Cell phone: Email: Email: Blood type: Organ/tissue donor: ❑ Yes ❑ No Citizenship: ❑ By birth ❑ By naturalization Naturalization date: Naturalization place (City State Country): Military veteran: ❑ Yes ❑ No Br

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