Care Needs Assessment

Stage 1 — Basic Profile Question 1 of 8

Stage 1 of 3 — Basic Profile

Question 1

Let's start with your name.

We'll use this to personalize your Care Summary.

Stage 1 of 3 — Basic Profile

Question 2

How can we reach you?

Please provide at least one — phone or email. Your Care Summary will be emailed to you at the end.

Stage 1 of 3 — Basic Profile

Question 3

The person needing care is your:

Stage 1 of 3 — Basic Profile

Question 4

How and when is the best way to reach you?

Preferred contact method:

Best time to reach you:

Stage 1 of 3 — Basic Profile

Question 5

What is your anticipated timeline for placement?

Stage 1 of 3 — Basic Profile

Question 6

Where is your loved one currently living?

Stage 1 of 3 — Basic Profile

Question 7

How does your loved one get around?

Stage 1 of 3 — Basic Profile

Question 8

How would you describe your loved one's current cognitive ability?

Choose the option that best reflects their day-to-day functioning.

You've completed Stage 1 — Basic Profile

You already have enough information for a useful Care Summary. You can generate your summary now, or continue for a more detailed assessment that covers specific care needs, medical considerations, and room preferences.

Stage 2 of 3 — Care Needs

Question 9

Does your loved one need assistance with bathing or showering?

Stage 2 of 3 — Care Needs

Question 10

Does your loved one need assistance with dressing?

Stage 2 of 3 — Care Needs

Question 11

Does your loved one experience incontinence or need toileting assistance?

Stage 2 of 3 — Care Needs

Question 12

Does your loved one need help transferring — moving from bed to chair, chair to wheelchair, etc.?

Stage 2 of 3 — Care Needs

Question 12b

Approximately how much does your loved one weigh?

This helps us determine staffing and equipment requirements for safe transfers.

Stage 2 of 3 — Care Needs

Question 13

Does your loved one have any of the following conditions?

Select all that apply. These conditions may affect placement options in a residential care home setting.

Exit-seeking behavior or history of elopement (wandering out of the home)

Insulin-dependent diabetes requiring injections

Feeding tube for nutritional intake

IV antibiotics or intravenous medications

Active contagious or communicable disease (MRSA, C. diff, etc.)

None of the above

Stage 2 of 3 — Care Needs

Question 14

Are there any behavioral concerns related to memory or cognitive changes?

Stage 2 of 3 — Care Needs

Question 15

Do you have preferences for room type or location?

Room type preference:

Location preference:

Stage 2 complete — great detail so far.

One final stage covers your financial situation and priorities — this helps us give you the most accurate guidance on fit and budget. It takes about two minutes. Or generate your summary now with what you've shared.