Client Evaluation

If you or a loved one are looking for answers, we may be able to help. Complete the short questionnaire below and one of our care coordinators will contact you within 24 hours to help you determine the level of care that is needed. There is no obligation and the assessment is free. We look forward to assisting you with your home care needs.

About the Client

1. Client’s Current Condition: Describe the client’s current condition in as much detail as possible.
2. Physician’s Diagnosis: Share the diagnosis provided by the client’s physician.
3. Is the Client Currently Receiving Home Care? Yes / No
4. Is the Client Ambulatory? Yes / No
   • Ambulatory with: Cane, Walker, or Wheelchair.
5. Is the Client Bedridden? Yes / No
6. Does the Client Bear Total Weight? Yes / No

Level of Assistance Required

7. While Ambulating, the Client Needs:

   • a) Heavy Assist / Continuous Hands-On Supervision
   • b) Moderate Assist / Stand-by Within Arms Length at All Times
   • c) Light Assist / Supervision and Queuing within Earshot

8. Does the Client Go on Walking Outings? Yes / No

9. Is Client Continent of Bladder? Yes / No

10. Is Client Continent of Bowels? Yes / No

11. Assisted Bathing? Yes / No

12. Assisted Meal Preparation? Yes / No

13. Assistance in General/Light Housekeeping? Yes / No

14. Assistance with Food Shopping? Yes / No

15. Assistance with Client Transportation? Yes / No

Type of Service Requested

16. Type of Service Requested:
    • Hourly
    • Daily
    • Weekly
    • 12 Hour Shifts
    • 24 Hour Shifts
    • Other

Comments: Please add any additional details that will help us understand your needs.

Thank you for taking the time to answer these questions. A Care Coordinator from Your Problems Solved will contact you within 24 hours.

Best Time to Contact You

• 8:00 am to 12:00 pm
• 2:00 pm to 5:00 pm
• 5:00 pm to 9:00 pm

Please contact me on Weekdays (Monday through Friday) only, on Weekends (Saturday or Sunday) only, or any day of the week.