Needs Assessment Questionnaire

Here are some simple questions to ask yourself to see if you should meet with a home care agency for a professional assessment of your needs and complimentary care plan.

1.  Is your house clean enough to meet your high standards?

• Yes
• No

2.  Are there chores around the house the you cannot currently do or that are becoming too much?

• Yes
• No

3.  Are you eating well enough consistently?

• Yes
• No

4.  Are you keeping your doctor appointments?

• Yes
• No

5.  Are you able to drive to your appointments as well as drive to all of your shopping needs (grocery/pharmacy)?

• Yes
• No

6.  Are you feeling overwhelmed taking care of your spouse?

• Yes
• No

7.  Are your children worried about you being alone or that taking care of your spouse is too much?

• Yes
• No

8.  Are you taking care of yourself everyday (exercise, proper diet, keeping your own doctor appointments, doing something fun a couple of times a week)?

• Yes
• No

9.  Would it be a benefit to have some assistance or companionship during the week?

• Yes
• No

Answer Key:

If you answered YES to questions #2, #6, #7 or #9 or NO to #1, #3, #4, #5 or #8 you should consider our services.

Only a few hours of professional caregiving each week can make a huge difference in your health and enjoyment of life. With Cottage Caregivers you can get just two hours a week to 24-hours a day – to support your independent life in your own home.