Consumer Needs Assessment

T.A.R.P. Center for Independent Living
Intake Form Consumer Needs Assessment

* Indicates required field

Name *

First

Last

Date *

Number in Household *

Head of Household *

Marital Status *

Number of children *

Emergency Contact Name *

First

Last

Emergency Contact Phone Number *

Living Situation? (Rent, Own, Live with Family/Friend, Homeless) *

Accessible? *

Relocated from Institution (date if applicable) *

Prevented Relocation (date if applicable) *

Transportation

Do you have transportation? *

Is your transportation unreliable? *

Notes *

Communication

Do you have difficulty understanding others? *

Do you have difficulty in understanding verbal instructions? *

Are you confident in making your own decision? *

Notes *

Self-Care

Do you need assistance with dressing? *

Do you need assistance with toileting? *

Do you need assistance with eating? *

Do you need assistance with grooming/personal hygiene? *

Notes *

Independent Living Daily Activities (Does not apply for young children/school age children)

Do you need someone to fix/cook your meals? *

Do you need assistance with shopping? *

Do you need assistance with household tasks (house cleaning, dishes….)? *

Do you need someone to tell you what time your doctor appointment is or what time to go to work? *

Do you need help with managing your money? *

Notes *

Equipment

Do you have difficulty getting to the bathroom? *

Do you need specialized equipment for the bathroom? *

Do you need specialized equipment activities of daily living? *

Notes *

Financial Management

Receiving SSDI/SSI? *

Do you have trouble finding or keeping a job? *

Have you ever participated in a sheltered workshop, transitional work training, supported employment, or a day activity center? *

Does your disability effect your ability to work? If yes please provide details in the box below *

Notes *

Food Security

Do you have enough food in your home? *

Do you need assistance getting SNAP benefits or commodities? *

Are you unable to get food and supplies due to lack of mobility or transportation? *

Notes *

Mobility

Do you have difficulty getting around the house, going to the mailbox….? *

Do you need specialized equipment for mobility? *

Do you need specialized equipment/transportation to leave the house? *

Notes *

Self-Direction

Do you have to be reminded to dress, eat, bathe….? *

Do you need someone to coordinate your personal care, social or medical services? *

Are you aware of dangers around you? *

Notes *

Education

Do you have trouble doing the same things your friends do? *

Are you currently a student? *

Did/Do you attend special education classes? *

Did/Do you have an IEP? *

Notes *

Social Needs

Does your social environment meet your needs? *

Notes *

Employment

Do you have gainful employment? *

Do you want gainful employment? *

Notes *

Health Insurance

Do you currently have health insurance? *

Do you have prescription coverage? *

Are you paying out of pocket for your prescriptions? *

Do you have Medicare? *

Do you have Medicaid? *

Do you have private/commercial insurance? *

Notes *

House Modifications for Access

Do you need a bathroom modification? *

Do you need a ramp for home access? *

Do you need other home modifications for accessibility? *

Notes *

Health/ Mental Concerns

Do you have any health needs that may need following up on? *

Are you in need of any further services such as counseling, physical/occupational therapy or any thing else of the sort? *

Notes *

Voting

Are you a registered voter? *

Would you like help registering to vote? *

I certify all information is true and correct to the best of my knowledge. *

Yes

By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this form. *

I Accept

ILS Signature *

Date *

Submit

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