CARER SUPPORT SERVICES:

CLIENT ASSESSMENT

CAR 532

Completed By:
Date:

Carer Alpha Code ☐ Care Recipient Alpha Code ☐

1 Care Information

Name
DOB / Gender / ☐ M ☐ F ☐Do not wish to answer
Address
Home Phone/
Mobile Phone
Email
Country of birth
Preferred Language / Interpreter required? / ☐ Yes ☐ No
Aboriginal or Torres Strait Islander / ☐ Yes ☐ No
Relationship to Carer

2 Emergency contact details

Name
Relationship
Home phone
Mobile


3 More client details

Employment
Pension/Allowance / ☐ Yes ☐ No
Accommodation type
Diagnosis
Current medication
Dietary requirements/allergies

4 Current situation: Do you require support in the following areas:

Alcohol Tobacco and Other Drugs / ☐ Yes ☐ No ☐Already receiving support
Mental Health/Emotional Wellbeing / ☐ Yes ☐ No ☐Already receiving support
Finance / ☐ Yes ☐ No ☐Already receiving support
Legal / ☐ Yes ☐ No ☐Already receiving support
Community Services / ☐ Yes ☐ No ☐Already receiving support

5 Other services involved

Service 1

Name
Agency
Type of support
Contact number
Consent to contact? / ☐ Yes ☐ No

Service 2

Name
Agency
Type of support
Contact number
Consent to contact? / ☐ Yes ☐ No

Service 3

Name
Agency
Type of support
Contact number
Consent to contact? / ☐ Yes ☐ No

Service 4

Name
Agency
Type of support
Contact number
Consent to contact? / ☐ Yes ☐ No

6 Current situation / routine

What is your current situation? What does a typical day look like for you?

7 Health and wellbeing and Self Care

How is your health at the moment? (e.g. physical, mental, emotional) Do you have any health conditions you have been told about by a doctor or other healh professional?

8 Interests and Additional Notes

What are your interests? Are there activities that you would like to try? Have you participated in group activities in the past? Is there anything that worked/didn’t work for you?

9 Life skills

(1= Frequent carer assistance, 2= some carer assistance, 3= no carer assistance)

House work / ☐ 1 ☐ 2 ☐3
Shopping / ☐ 1 ☐ 2 ☐3
Cooking/preparing meals / ☐ 1 ☐ 2 ☐3
Showering / ☐ 1 ☐ 2 ☐3
Personal Hygiene / ☐ 1 ☐ 2 ☐3
Personal Presentation / ☐ 1 ☐ 2 ☐3
Getting up in the morning / ☐ 1 ☐ 2 ☐3
Time organization / ☐ 1 ☐ 2 ☐3
Planning activities / ☐ 1 ☐ 2 ☐3

Social skills

Engaging in one-to-one conversation / ☐ 1 ☐ 2 ☐3
Able to meet new people / ☐ 1 ☐ 2 ☐3
Able to ask for information/assistance / ☐ 1 ☐ 2 ☐3

Cognitive and behaviour

Remember recent events clearly (hours/day – short term memory) / ☐ 1 ☐ 2 ☐3
Remember distant events clearly (months/years – long term memory) / ☐ 1 ☐ 2 ☐3
Following instructions / ☐ 1 ☐ 2 ☐3

Physical health and nutrition

Regular exercise / ☐ 1 ☐ 2 ☐3
Regular meals / ☐ 1 ☐ 2 ☐3
Doc No: CAR 532 / Version No: 1 / Date of Issue: 18/06/2015
Author Title: MB / Authoriser Title: DSD / Approver Title: CEO
CONTROLLED COPY / Uncontrolled Copy When Printed
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