Self-Care Services Eligibility Form
Please complete this form to help us assess your eligibility for self-care services. All information will be kept confidential.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Female
Male
Non-binary
Prefer not to say
Other
Current Living Situation
*
Live alone
Live with family
Assisted living facility
Other
Do you have any existing medical conditions or disabilities?
*
Mobility impairment
Visual impairment
Hearing impairment
Chronic illness
Cognitive impairment
None
Other
Which self-care services are you interested in?
*
Personal hygiene assistance
Meal preparation
Medication reminders
Mobility support
Housekeeping
Other
Please rate your ability to perform the following daily living activities:
*
Rows
Independently
With some help
Need full assistance
Bathing
1
2
3
Dressing
4
5
6
Feeding
7
8
9
Toileting
10
11
12
Transferring (e.g., bed to chair)
13
14
15
Are you currently receiving any support for your self-care needs?
*
Yes, from family or friends
Yes, from a professional caregiver
No support at this time
How urgent is your need for self-care services?
*
Not urgent
1
2
3
4
Very urgent
5
1 is Not urgent, 5 is Very urgent
Is there any additional information you would like to provide regarding your self-care needs or circumstances?
Submit Eligibility Form
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