Care Assessment

Let's Get Started

Tell us a little about yourself or your loved one to personalize your assessment.

Care Recipient's Name

Age

Your Relationship

Michigan Location

Current Living Situation

Living Independently Living with Family

Daily Living Activities

Help us understand current abilities and where gentle assistance might be helpful.

Bathing and Personal Hygiene

Completely Independent Needs Some Assistance Needs Full Assistance

Dressing and Grooming

Completely Independent Needs Some Assistance Needs Full Assistance

Getting Around and Mobility

Walks Independently Uses Walker/Cane Uses Wheelchair

Safety and Independence

Let's discuss any safety concerns and independence goals.

Current Safety Concerns

I Have Safety Concerns No Major Concerns

What are your main goals for maintaining independence?

Companionship and Activities

Tell us about social needs and preferred activities.

How often would you like companionship?

What activities would you enjoy with a caregiver?

Social Activities Quiet Activities

Household Support

What household tasks would be helpful to have assistance with?

Meal Preparation

Housekeeping Tasks

I Need Housekeeping Help No Housekeeping Needed

Transportation Needs

What transportation assistance would be helpful?

Transportation Services

I Need Transportation No Transportation Needed

How often would you need transportation?

Care Schedule and Contact

Let's finalize your care preferences and get your contact information.

Preferred Care Schedule

When would you like to start care?

Your Contact Information

Your Name

Phone Number

Email Address

Best Time to Contact

Additional Information

Assessment Complete!

Thank you for completing our care assessment. Here's a summary of your responses:

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