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Personalized Care Starts Here: Share Your Loved One’s Needs

Assessment Form

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<h3>Complete Our Assessment Form</h3>
<p class="large">Help us start determining your loved one’s care needs by sharing as much information as possible. Your input will help us create a personalized care plan that ensures their comfort, safety, and well-being.</p>

name

email

Prospective Resident's Name

Date of Birth

Your Relationship to Prospective Resident

Self

Family Member

Friend

Case Manager

Other

Reason for Seeking Care - What has prompted you to look for care at this time?

General assistance with daily activities

Memory or cognitive support

Social engagement and community living

Safety and security concerns

Recovery from surgery or illness

Daily Living Preferences - What areas of daily assistance are needed at this time?

Bathing and dressing

Mobility assistance

Medication reminders

Meal preparation and dining assistance

Continence care

Housekeeping and laundry

Social activities and engagement

Mobility - How would you describe the resident’s mobility?

Fully independent

Uses a walker or cane

Requires assistance with walking

Primarily uses a wheelchair

Needs help transferring in and out of bed/chair

Cognitive and Emotional Needs - Are there any specific cognitive or emotional needs?

Memory care support

Assistance with decision-making

Assistance with Eating

Emotional support for anxiety or depression

Social engagement challenges

Social & Activity Preferences - What types of activities does the resident enjoy?

Physical activities (e.g., exercise, walking)

Creative arts (e.g., painting, crafts)

Music and entertainment

Social games (e.g., bingo, cards)

Quiet activities (e.g., reading, puzzles)

Outings and excursions

Meal Preferences - Are there any dietary restrictions or preferences?

Diabetic

Low-sodium

Vegetarian

Gluten-free

No specific restrictions

Personal Care Preferences - Are there any particular care preferences we should know about?

Is there anything else you would like us to know about the prospective resident to help us understand their needs better?

Prospective Move-In Date

Next Steps - How would you like us to follow up with you?

Phone Call

Email

phone

message

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Seniors at restaurant

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Contact our team at Your Thyme To Shine to schedule an assessment for your loved-one.

Assessment Form

Complete Our Assessment Form

Schedule an Assessment