A 13-page Word in-home assessment for a non-medical home care agency, used at the start of care and at each reassessment to plan help, safety, and schedule.

For USA home care agency owners, supervisors, and assessors. Plus 1 agency instructions page to remove before use.

What’s included

1. Pages 1-2: assessment and client details, emergency contacts, language, home access, and household
2. Pages 3-4: transportation, daily routine, night-time, memory, mood, senses and communication
3. Pages 5-7: personal care, moving and equipment, household tasks, and meals, each with a help key (I / SU / SB / HO / None)
4. Pages 8-9: falls and home safety walk-through, emergency plan, health matters as reported, allergies, medication reminders, and providers
5. Pages 10-11: interests, social life, routine appointments, safety follow-up, and caregiver match
6. Pages 12-13: goals, service type and schedule wanted, acknowledgment and signatures, and Agency Use Only review
7. Agency instructions page, to remove before use

Add your logo and name

1. Open the Word file and replace the Your Logo Here box with your logo.
2. Replace Agency Name in the letterhead and in the page header (double-click the top of any page); the body says “the Agency,” so no other name edits are needed.
3. Replace the Street Address, City, State ZIP line and the Phone, Email, Website line with your details.
4. Set the letterhead text to black, delete the instructions page, and save.

Customizable template, not legal advice; check your state’s requirements. Not a license to operate, not HIPAA software, and no medical claims. A non-medical planning form: it records what the client and family report and what is observed, with no diagnoses or clinical scores.