Home About Us Programs Staff Is There A Need Contact Us
Services
Signature Care Rise and Shine Bath Care Comforting Care Homemaker and Companion Service Friendly Visitor Extra Hands Cleaning Chore and Seasonal Cleaning Respite Care Nursing Care Professional In-Home Care (State Grant) Family Care CASE - Child Abuse Service In An Emergency FIC - Family in Crisis ECS - Emergency Chore Service SCILS - Senior Community Independent Living Services Phillips Lifeline Healthy Workforce Care Management
 
Is There A Need?
The following questions are designed to assist you in identifying the need for home care and the level of care necessary.
1. Please choose the best answer that describes the person needing care:
General Health
Frail Poor Fair Good  
Does the person needing help have a physical disability?
  Yes No    
What is the person's age?
86 or older 85-71 70-60 59 or younger
Please select the statement that best describes the person's current living arrangement.
  Alone without needed help   Alone, has help   With someone who can't help   With someone who can help   Self-sufficient
Please select the statement that best describes the person's current mental condition.
  Diagnosis of Alzheimer's or other mental dysfunction   Frequent confusion and/or disorientation   Sometimes confused and forgetful   No Problem

2. How difficult is it for the individual needing care to perform the following activities of daily life:
  Very Moderately No Difficulty
Personal care and Grooming        
Ability to get around in the house        
Managing the household tasks        
Meal preparation and nutrition        
Getting out of the home to shop, etc.        
Socialize with others        
Medication compliance        
         

3. Does the person rely on others for these tasks?
  Yes No    

4. Has there been deterioration in the physical or mental health of the individual or in the ability to manage daily activities within the past 6 months?
  Yes No    

5. Does the need for care create stress for you or other family members?
  Yes No    

6. Is your concern magnified by any of the following (check all that apply)
  Family tension
  Lack of knowledge
  Inability to provide care due to personal commitments, distance, etc.
  Feeling of being overwhelmed

7. Is the person in need of care able to handle an emergency in the home?
  Yes No    

8. If something doesn't change, will it be difficult or impossible for this person to stay at home?
  Yes No    

9. Are you worried about this individual?
  Yes No    
   
 
Copyright 2007-2008 © Visiting Homemaker Service.
All rights reserved. Privacy policy.

CALL TOLL FREE
Visiting Homemaker Service of Hudson County
586 Newark Avenue, Jersey City, New Jersey 07306

Content Management System Provided By:Timberlake Publisihing