Needs Assessment


Since no two people are the same, Crossroads Homecare conducts a confidential, in-home assessment to gain a better understanding of your (and your family's) specific needs and expectations. This initial meeting provides you and us with the opportunity to learn about each other and to address any questions you may have about our service.

Our in-home assessments are free of charge and there is no obligation. The assessments will allow us to create a customized service solution for you. During this session, we review and discuss the following topics:

NON-MEDICAL HOME CARE ASSESSMENT FORM

*Note: All scores are calculated based on the number of hours care would be required during a five (5) day period.

ACTIVITY CLIENT ABILITY AVERAGE SCORE* CLIENT SCORE*
Using Telephone Able to look up numbers, dial, receive and make calls without assistance 0
Able to answer phone or dial operator in an emergency, but needs some assistance when making calls 1
Unable to independently use a telephone 2
Ambulation Able to ambulate freely 0
Able to ambulate w/ assistance of a cane/walker. Requires minimal supervision in the home, but more supervision outside of the home; i.e. getting mail, going up or down stairs, longer walks, etc. 2-3
Prone to falling. Unable to ambulate w/out supervision 5-10
Shopping, Driving and/or Traveling Able to independently handle all shopping, driving and/or traveling 0
Requires some assistance 2-4
Unable to perform these tasks independently – assistance required 10
Preparing Meals Able to plan & prepare all meals 0
Able to prepare light meals & cold meals, but not full meals 5
Unable to prepare any meals independently 10
Performing Household Work/Chores Able to do all household work/chores 0
Able to do light housework but requires assistance with some chores; i.e. laundry, garbage 5
Unable to do any housework 10
Taking Medication Able to prepare and take all medication 0
Able to prepare and take medication but needs reminding 5
Unable to take medication without assistance– (Companion unable to Assist) 10
Managing Money/Mail Able to manage buying needs, write checks, pay bills, open and respond to mail 0
Can perform some of these tasks independently but not all 3-5
Unable to perform these tasks 5
TOTAL CLIENT SCORE  
Client Information: