Self-Evaluation

Seniorcorp

SELF-EVALUATION

Questions Regarding The Individual Needing Help:


1. Does this person live at home?	Yes No

2. Does this person live alone?	Yes No

3. Does the family live out of town?	Yes No

4. Is the family often unavailable to help?	Yes No

5. Does this person need help with their daily activities?	Yes No

6. Is this person becoming less independent?	Yes No

7. Does this person feel like a burden?	Yes No

8. Do others feel burdened by caregiving?	Yes No

9. Is this person scared or depressed?	Yes No

10. Is this person, or the family, overwhelmed in managing care?	Yes No

11. Is this person receiving homecare or medical treatment at home?	Yes No

12. Are normal tasks, such as shopping, driving, paying bills, cooking, or hygiene beginning to suffer?	Yes No

13. Do you currently reside in Virginia?	Yes No

14. Are there resources available to pay for services?	Yes No

If you answered YES to one or more questions, Seniorcorp may be right for you. Please fill out the remaining information and click on "SEND MY INFORMATION" and someone will contact you soon. Click to review our Privacy Policy for information you submit.


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