Client Assessment Form

Name of Person Doing the Assessment:	*
Relation to Client:	*
Date of Assessment:	*
Name (Last, First, MI):	*
Address(city, State zip):	*
Phone Number(s):
Email Address:	*
Date of birth:	/ / *
Emergency Contact:(You may use as much space as needed in the text area on the right)	*
Dare to Dream Attendant Services wants as much customer input to better serve you. Please answer the below questions as detailed as possible. If you have questions please call the office of Dare to Dream Attendant Services.
Disability (Mental/Physical):
Name of Physician:
Name of Pharmacy:
Medical Allergies:
Dietary Restrictions/ Allergies:
Do you smoke?	Yes No If so, how often?
Do you drink?	Yes No If so, how often?
What medications are you currently taking? Please list dosages and times taken as well.
Are there any other physician recommended therapies that you are being treated under?
Have you ever lived independently before?	Yes No
What are your goals?
What are your current living arrangements (ex. Care facility, live alone, etc.)?
Do you have a representative or a guardian besides yourself?	Yes No
If so, what is their Name and Contact information?
Do you have an advance directive, living will, do not resuscitate order, or any other directions for your end of life arrangements?
Do you plan to go into hospice care?	Yes No
Do you have an emergency evacuation plan? Yes No if so please briefly describe.
Do you receive any Public Benefits or Entitlements? Yes No Check below if applicable: SSI SSDI IHSS Veterans Benefits Medi-CAL Medicare Regional Center Services Department of Rehab Social Worker/Counselor
Please specify any other agencies you work with or have worked with:
Do you use any durable medical equipment (DME)? Yes No
Please check, and list the equipment, Brand name (BN), year of purchase (YOP) and Vendor (V) you use for repairs and replacement:
Mobility Equipment (ex. wheel chairs, walkers, etc.):	BN YOP V
Hospital bed:	BN YOP V
Air mattress:	BN YOP V
Sleeping Aids (ex. Pillows, nebulizer, etc.):	BN YOP V
Respiratory Equipment:	BN YOP V
Bathroom equipment (ex. Grab bars, shower chair, etc.):	BN YOP V
Communication:	BN YOP V
Electric toothbrush:	BN YOP V
Electric Shaver:	BN YOP V
Other:	BN YOP V
Number of Hours of Attendant Care Requested:
Please check: Non Personal Care Personal Care Both
Gender Preference: Male Female
Number of Coordination Hours Requested (per month):
Do you work? Yes No If so, Where?
Do you drive? Yes No
Do you need someone to drive for you? Yes No
Do you like to shop with someone? Yes No
Do need someone to shop for you? Yes No
Do you have things at home that you wish to be kept private from others?
When do you like to take a bath or a shower?
Is there any part of your house that is inaccessible? Yes No If so please describe:
Do you wish to have assistance with the following: (Please check all that apply) Opening mail Sending Letters Signing your name Using the telephone Writing down messages Checking Email Help with your finances Paying your bills Writing Checks Going to the bank/Using ATM
What time do you prefer to wake up?
What does your morning routine involve?
How do you like to dress? Casual Formal Professional
Does this change on weekends, holidays and special occasions? Yes No
What do you like to eat for your meals?
Breakfast:
Lunch:
Dinner:
Snacks:
What following tasks you would need help with in the morning? Getting out of bed/Transferring Dressing Feeding Shaving Brushing Teeth Washing face Brushing Hair Pet Care Exercising/ROM Other:
Please tell us what you like doing during the day?
What time do you go to bed?
Do you need to have access to any equipment in bed at night? (examples: Sleeping equip., remote for television, etc.):
Do you need assistance during the night? (examples: going to the bathroom, repositioning, etc.):
Is there any additional information that you would like to share with us?
All information will be kept confidential and secure.