Healthcare Program Entrance Assessment Form
Complete this Healthcare Program Entrance Assessment Form to help us understand your background, care needs, participation readiness, and overall fit for our healthcare program.
Full Name
*
First Name
Last Name
Preferred Contact Method
*
Phone
Email
Mail
Age Group
*
Please Select
Under 18
18-29
30-44
45-64
65 or older
Current Living Situation
*
Alone
With family
With caregiver
Other
Primary Reason for Seeking Program Entry
*
Level of Support Needed for Daily Activities
*
1
2
3
4
5
How would you rate your readiness to participate in a structured healthcare program?
*
Not ready
1
2
3
4
Very ready
5
1 is Not ready, 5 is Very ready
Please indicate your ability to perform the following activities independently.
*
Rows
Independently
With some help
With full assistance
Personal care (e.g., bathing, dressing)
1
2
3
Meal preparation
4
5
6
Medication management
7
8
9
Mobility (moving around)
10
11
12
Have you participated in any similar programs before?
*
Yes
No
Is there anything else you would like us to know regarding your care needs or program expectations?
Submit Assessment
Should be Empty: