Claimant Care Needs Assessment Form
Use this form to assess a claimant’s care needs, daily support requirements, timing, and follow-up contact preferences. Do not include sensitive personal or financial information.
Claimant Details
Claimant Name
*
First Name
Middle Name
Last Name
Relationship or Role to the Person Needing Care
*
Self
Parent
Child
Spouse or Partner
Sibling
Other Family Member
Friend
Carer or Support Worker
Other
Preferred Contact Method
*
Please Select
Phone
Email
SMS
Postal Mail
Other
Care Needs Assessment
Primary care need category
*
Mobility
Personal care
Meal support
Medication support
Transport
Supervision
Other
Level of assistance required
*
Minimal assistance
1
2
3
4
5
6
7
8
9
Full assistance
10
1 is Minimal assistance, 10 is Full assistance
Care tasks support areas
*
Support Context and Timing
When is support needed?
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
How often is care needed?
*
One-time
Daily
Several times a week
Weekly
As needed
Other
Additional notes or special circumstances
Submit
Should be Empty: