ASSISTED LIVING FOR
THE ELDERLY
24 Hours/7 days a week
    
Needs Assessment Form

Please fill out our assessment form so we can accurately evaluate your care needs.
For whom are you seeking assitance?


Which of these tasks does the person need assistance with?
Eating
Dressing / Grooming / Hygiene Assistance
Transferring
Assistance in the bathroom
Bathing
Monitoring Oxygen

Does the person display any of these behaviors?
Confusion about where he or she is
Verbal or Physical Aggression
Forgets the values of close family members or friends
Wanders away from home

Which medical conditions does the person have?
Alzheimer or Dementia
Cancer
Stroke
Pulmonary (Lung) Disease
Heart Problems/Other Circulatory Problems
Recovering from surgery
Diabetes
Parkinson Disease
Multiple Sclerosis
Kidney disease
Arthritis/Other musculoskeletal problems
Depression
Psychiatric

What are some of his/her major needs?
Respite Care
Colostomy Care
Hospice Care
Transportation to medical appointments
Management of overall care needs
Social and recreational activities

How mobile is this person?
Walks without assistance
Immobile
In a Wheelchair
Uses a cane/walker
Needs assistance in walking

Please provide the following:
Your Name*
E-mail*
Phone*

Comments
Monthly Budget*

* denotes required fields

OUR PRIVACY POLICY: We take your personal privacy very seriously.
Any information you provide to Compassionate Care Homes via email or any other method is never used for any other purpose except for that which it is intended.

  Our Mission

Our purpose is to provide excellent care and services to the residents and to be supportive of their needs.

 Our Commitment

We, at Compassionate Care Homes, provide a loving alternative with a family atmosphere, for the care of the elderly. We believe in competent, quality care and are very sensitive to individual needs.

Call for a tour:
(916) 536 - 1343

Or e-mail:

Location:
Greater Sacramento Area / Fair Oaks, California

CA License No. 347000691
CA License No. 347002382
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