Care Assessment Questionnaire

 

Please click on the Submit button to submit the form details.

 

* indicates required fields 
  Do you live alone?:
  Do you use assistance devices?:
  Have you been hospitalized in the past year?:
  If yes, How many times?:
  What was the reason?:
  Do you take prescription medications?:
  Do you need help to walk, bathe, dress, or eat?:
  Do you feel socially isolated?:
  Can you easily cook, clean, shop, do laundry?:
  Have you made care plans if you can't speak?:
  Do you need someone to check on you medically?:
  Have home safety hazards been removed?:
  Do you have memory or judgement problems?:
  Are you losing weight?:
  Do you have difficulty moving around?:
  Is it hard for you to bathe or dress yourself?:
  Can you cook full meals everyday?:
  Can you do your own laundry?:
  Do you need transportation to places?:
  Do you worry how to take care of your house?:
  Do you want to know more about our services?:
  *Your Name:
  *Your Phone Number:
  Your Email Address:
  Your Address:
  Specific Location Details:
Please click on the Submit button to submit the form details.
 
Non Discrimination Policy: 
Caring Companions consistently strives to provide quality services to our clients in accordance with the highest ethical standards. We will not discriminate on the basis of, race, color, religion, veteran status, marital status, citizenship status, gender preference, national origin or disability or age in admission to, participation in, or receipt of the services and benefits of any of its programs and activities or in employment therein, whether carried out by Caring Companions by: Brenda Metal, LLC directly or through a contractor or any other entity with whom Caring Companions by: Brenda Metal, LLC arranges to carry out its programs and activities.   This statement is in accordance with Title VI of the Civil Rights Act of 1964, section 504 of the Rehabilitation Act of 1973, the Age discrimination Act of 1975, and the Regulations of the U.S. department of Health and Human services issued pursuant to these statutes at Title 45 Code of Federal Regulations Parts 80, 84, and 91.
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