Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Companionship *

+4 - Family involved in daily activities

+3 – Family lives in the same city

+2 - Family lives in different city

+1 – Family lives out of state / no family assistance

Cleaning *

+4 – Maintains house upkeep on their own or with minimal assistance

+3 – Needs some assistance with daily house chores but can perform light tasks like dish cleaning and bed making

+2 – Requires significant assistance with daily housekeeping

+1 – Cannot maintain an acceptable level of cleanliness on their own

Meal Preparation *

+4 – Plans, prepares, and serves adequate meals independently

+3 – Needs some assistance; can complete simple tasks like peeling potatoes and chopping vegetables but needs help cooking or operating kitchen appliances

+2 – Can plan adequate meals but requires full assistance with preparation and cooking

+1 – Cannot plan or prepare their own meals at all

Errands *

+3 – Takes care of all shopping needs independently, including for groceries and other necessities

+2 – Needs some assistance or guidance while shopping/running errands

+1 – Cannot not shop on their own at all

Transportation *

+3 – Travels independently on public transportation or drives their own car

+2 – Cannot operate their own vehicle but can manage adequate use of public transportation with assistance or accompaniment

+1 – Does not drive or arrange their own rides at all; fully reliant on someone else for travel needs

Laundry *

+3 – Washes, folds, and stores personal laundry completely on their own

+2 – Needs some assistance with laundry but can launder small items

+1 – Cannot do laundry on their own at all

Self-administering Medication *

+4 – Does not take medication

+3 – Responsibly takes their medication in correct dosages at correct time without assistance

+2 – Needs assistance managing medications; takes medications responsibly if they are prepared or distributed in advance by another person

+1 – Cannot dispense their own medication at all