Warm Welcome Assessment

1Get Started

2Physical Health

3Mental Health

4Living Environment

5Pictures

*Admin - cid1

*Admin - activity1

Warm Welcome Assessment

You are filling out this Warm Welcome form to assess the physical and living conditions of our new older adult member. If any of the information above is not correct, please contact Emma (emma@alittlehelp.org) to provide a correction.

Name:

Address:

Phone:

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Name

First Last

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Address

Street Address Address Line 2 City State ZIP Code

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Phone

Physical Health

Now, please verify the information provided below, and update where necessary.

MOBILITY: Does the member have mobility issues?

Yes

MOBILITY: Aid

Cane

Walker

Wheelchair

Other

MOBILITY: Other aid

VISION: Does the member have vision issues?

Yes

Additional details about your vision:

!! - What type of vision issues? on warm welcome

VISION: Aid

None

Cane

Guide dog

Other

VISION: Other aid

HEARING: Does the member have hearing issues?

Yes

HEARING: Aid

Yes

HEARING: Other aid

Is the member on oxygen support?

Yes

Any recent injury or hospitalization?

Yes

Recent injury / hospitalization date

MM slash DD slash YYYY

Injury / hospitalization details

Additional comments about the member's physical condition

Mental Health

Have you already submitted Mental Health details for this member?

No: this is the first time I'm submitting this form for this member

Yes: I have already submitted Mental Health information for this member, and I am now only updating other questions on this form

Mental Health Assessment:

Do you feel like the member is dealing with grief or other emotional challenge?
Is the member showing signs of challenged coherence or other mental impairment?

UCLA Loneliness Scale Questions

Please use the following text to introduce the next 3 questions to the member:

"I have 3 questions that are part of a scale used to assess feelings of loneliness or social isolation. It's called the UCLA Loneliness Scale. A Little Help uses it to better understand how our members are feeling and hopefully measure the impact that A Little Help has over time."

!ncpc! How often do you feel that you lack companionship?

Never

Rarely

Sometimes

Often

!ncpc! How often do you feel isolated from others?

Never

Rarely

Sometimes

Often

!ncpc! How often do you feel left out?

Never

Rarely

Sometimes

Often

Living Environment: Indoor

Please provide your own personal assessment of the indoor living conditions. If an answer has already been provided, please validate or update where necessary.

Are there smokers in house?

Yes

Are there pets in the house?

Yes

*Type of pets

Cat

Dog

Bird

Other

Would you say the member has hoarding tendencies?

Yes

Here are illustrations of 3 levels of hoarding:

Image

Level 1

Image

Level 2

Image

Level 3

Would you qualify the hoarding level in the house to be more like:

Level 1

Level 2

Level 3

Are there any obstructions throughout the house causing safety concerns?

Yes

Please provide details about the 2 questions above

You will also be able to upload a few pictures at the end of this form, to illustrate the living environment of the member.

What health hazards have you observed in the house?

no health hazards

no heating / cooling

drafty

mold

bad smells

general dirtiness

pests

Is there evidence of used incontinence products?

Yes

Please provide details

Are there stairs in the home or to access it?

In the home or outdoor to access it

indoor

outdoor

wheelchair ramp/lift

no stairs

Living Environment: Outdoor

Please provide your personal assessment of the overall exterior of the property.

What type of home does the member live in?

Single family home

Duplex

Condo / Townhome

Apartment

*How would you qualify the front yard?

big

medium

small

no yard

*The backyard?

big

medium

small

no yard

Is there trash or debris accumulating in the yard(s)?

Yes

What is the overall state of the yard(s)?

well kept

unkept

abandoned

What is the general state of the house exterior itself?

good condition

some work needed

disrepair

Notes on Outside Yard and Home

Pictures

You can upload here up to 5 pictures illustrating the living conditions of the member. Please be respectful and ask for permission when taking pictures of the member's home.

File

Drop files here or

Max. file size: 16 MB, Max. files: 5.