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 recor

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 sur

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: