Living Alone Risk Assessment Form
Use this form to assess daily safety, support needs, and follow-up preferences for someone living alone.
Living Situation
Living arrangement
*
Living alone
With roommates
With family
Other
Neighborhood or city context
Daily Safety and Support Assessment
How confident are you in handling daily tasks on your own?
*
Not confident
1
2
3
4
5
6
7
8
9
Very confident
10
1 is Not confident, 10 is Very confident
How often can you get help quickly if you need it?
*
1
2
3
4
5
Do you have a regular person who checks in on you?
*
Yes
No
Sometimes
Not sure
Which of these areas feel like possible risks right now?
*
Rows
No concern
Some concern
High concern
Falls or balance
1
2
3
Missed medications
4
5
6
Food access
7
8
9
Emergency response
10
11
12
Moving around safely
13
14
15
Is there an emergency contact available if needed?
*
Please Select
Yes, available anytime
Yes, but only sometimes
No, not available
Not sure
Are there any immediate concerns that need follow-up now?
*
No immediate concerns
Yes, minor concern
Yes, urgent concern
Not sure
Follow-up Preferences
Preferred follow-up method
*
Phone
Email
Text
None
Additional notes or support needs
Submit Assessment
Should be Empty: