Initial and Annual Assessment
Consumer Name (first, middle initial, last name):
Date of birth:
Date Completed:
Instructions for use: Mark if this assessment is annual or initial. Meeting with the individual and support members of their choice, ask each question in succession. Answers should be recorded in full sentence form so that when they are read in succession the answers create a story, without need to summarize.
Initial AssessmentAnnual Assessment
Contributing staff or family:
Community Living
Living Arrangement:
Do you live in a home that you like, or is there someplace else you would like to live?
Who do you live with? Do you like who lives with you?
Do you live in a home where you feel safe and meets your needs?
YesNo
Transportation:
How do you get to the places you need to go? (Do you have yourdriver’s license? Use public transportation? Walk?)
Community Access:
Is your home located near places you like to go?
YesNo
What supports do you need, if any, to access the community events or go to the places you want to go?
Adaptations/Modifications:
In your home are there rails for the stairs or bathrooms? Is there a ramp?
YesNo
If your home is not accessible, what do you need support with, or what would make you feel safer in your home (such as better locks)?
Social and Spirituality
Communication:
How do you communicate with your family and friends? (letters, phone, email, sign language, communication device)
Are you a member of, or would you like to be part of any social media to help you keep in touch with others? Which ones?
Is there a way others could help you communicate with your family and friends?
What hurts your feelings or upsets you?
What do you do when others hurt your feelings or make you angry?
Natural Supports:
Who is in your family (Pets can be included!)?
Who are your friends?
Is there anyone else who is important to you, such as a boyfriend or girlfriend?
What do you enjoy doing with your family and friends?
Strengths:
What are you really good at?
What do people like about you?
Community Connections:
Where do you go to church?
If you do not, would you like to? Have you attended a particular church in the past?
Are you part of any clubs or organizations such as People’s First, a Church, or some other social group?
YesNo
If yes, what groups?
Daily Life
Home:
What do you do each day? (How do you wake up? Do you bathe? Brush your teeth? Complete household chores? Go to work or school? Cook using a stove or microwave? Take your medication independently?)
What choices do you have the opportunity to make each day? (Such as what you want to eat, wear, or do)?
What do you like to do in your free time?
Is there anything you would like to learn how to do as a hobby or a special interest to you? (Such as knitting or reading?)
What are your favorite books, magazines, TV shows, movies, or websites?
School:
Do you receive any therapies, adaptations, or attend any specialized classes?
What skills are you focusing on?
Employment:
Do you have a job or do you volunteer anywhere? (If they are a student, ask these questions pertaining to their school or class work).
YesNo
If so, where?
What are your responsibilities there?
Do you enjoy your job and the people you work with? Why or why not?
If not, would you like to work, and what would you like to do? (For students: do they want to go to college?)
What skills are necessary to do the job you want? (What do students need to do to get into college and be successful?)
Services and Supports:
What supports do you currently receive to help you with your day to day life or accessing resources (give examples such as LOQW’s support, a neighbor helping them, their support coordinator).
How do these people help you?
Is there anything you would like for your current support staff to do to help you?
Is there something you would like support on, but aren’t sure who to ask?
What characteristics do you like/dislike in your support staff?
What do you need help with and *what can others do to help you?
*If you need help with something, who can you call or where can you go for help?
What supports do you need to access and sign up for?
Financial:
In your daily spending money, how do you choose to spend it? How do you choose to budget your money?
What services do you receive from the state, such as SSI (Supplemental Security Income), Medicaid, or Foodstamps?
Safety and Security
Emergency Planning:
What is your plan if there is a natural disaster such as a tornado or earthquake in all environments? Do you need help developing and practicing that plan?
Who do you have designated to call, outside of emergency services, in case of an emergency or natural disaster?
How and who do you call for help when you are in your home? When you are in the community (work, school, etc.)?
Legal:
Who are your legal guardian and/or Payee? How do they support you? (paying bills? Spending your own money? Choosing where to go?)
Are you a registered voter?
Client Rights:
Who can you designate to contact if you feel that you are being abused or disrespected by others?
What would you do, or who would you go to, if you thought you were not being respected by your support staff?
Level of Support:
Are you able to stay or live alone in your home? If not, what supports do you need?
How do you practice safe pedestrian skills?
Healthy Living
Medical:
Who are your physicians and how often do you see them?
Primary:
Dental:
Vision:
Audiologist:
Psych:
Specialists:
Who can you ask for support if you aren’t sure what questions to ask your doctor or how to make an appointment?
Do you know what medications you are prescribed?
Why are you taking these medications?
Is there any support that would help you with your medications?
What allergies do you have?
Physical:
What exercise or physical activity to participate in? How often do you exercise or do this activity?
Nutrition:
Do you have a special diet?
Behavioral Health:
Do behaviors result in aggression to self or others?
Are any behaviors displayed that affect your health?
Are you receiving therapies?
Do you take psychotropic medications? If so do you receive an annual Tardive Dyskenesia screening?
Citizenship and Advocacy
Advocacy:
How do you advocate for yourself? (Do you tell others when they do things you don’t like? Do you tell others when you need or want something?)
Do you need more support than you already have to advocate for your wants or needs?
YesNo
How can others support you in this?
Individual Goals, Dreams, Hopes, and Wants:
Last year’s goals and progress:
What goals did you work on this last year, and what have you learned how to do?
What goals would you like to work on this year and what would you like to learn how to do?
Family/Guardian Goals/Vision:
Other areas of discussion:
______
Individual SignatureDate
______
Service Coordinator Signature Date
All Life Category logo and graphics came from the Missouri Family to Family resource guide and can be found at: