Assessing for Service and Support Needs

Many people with your condition benefit from services and supports. Let’s assess what you need now. We can do this assessment periodically if your needs change. Caregivers also need support. A separate assessment should be done to assess the needs of your supporters.

1. Do you need help making decisions? o Yes     o No  

If yes, do you have someone you trust to help you make decisions? o o Yes     o No    

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2. Do you need help with managing symptoms? o Yes     o No    

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3. Do you need personal assistance to assist with activities of daily living or to go out into the community? o Yes     o No    

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4. Is your home accessible? o Yes     o No    

If not, can your home be made accessible with adaptations? o Yes     o No     o Not Sure

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5. Do you need referrals to housing programs? o Yes     o No    

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6. Do you need a home assessment for adaptive equipment? o Yes     o No    

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7. Do you need mobility devices? Would you like a Physical Therapy assessment to make recommendations? o Yes     o No    

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8. Do you need adaptive equipment to do your activities of daily living? Would you like an Occupational Therapy assessment to make recommendations? o Yes     o No    

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9. Do you have reliable transportation? Do you need information or referrals for accessible transportation options? o Yes     o No    

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10. Do you need help with legal arrangements? o Yes     o No     o Not Sure

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11. Do you need help with financial arrangements? o Yes     o No     o Not Sure

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12. Do you need accommodations at work? o Yes     o No    

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13. Do you need social support? o Yes     o No    

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14. Do you feel safe and supported at home? o Yes     o No    

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