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Home
About US
Services
Family Support
Services
Resources
Calendar
CIL's in TN
Donate
Contact Us
T.A.R.P. Center for Independent Living
Consumer Needs Assessment
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Indicates required field
I am filling out this form for someone else
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Yes
No
Name of Person filling out form
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First
Last
Name of Person needing services
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First
Last
Date
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Email
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County of Residence
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Home Phone Number
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Cell Phone Number
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Number in Household
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Head of Household
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Yes
No
Marital Status
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Number of children
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Emergency Contact Name
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First
Last
Emergency Contact Phone Number
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Housing
Living Situation? (Rent, Own, Live with Family/Friend, Homeless)
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Accessible?
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Yes
No
Relocated from Institution (date if applicable)
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Prevented Relocation (date if applicable)
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Notes
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Transportation
Do you have reliable transportation?
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Yes
No
Notes
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Communication
Do you have difficulty in understanding others or understanding verbal instructions?
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Yes
No
Are you confident in making your own decisions?
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Yes
No
Notes
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Self-Care
Do you need assistance with dressing?
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Yes
No
Do you need assistance with toileting?
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Yes
No
Do you need assistance with eating?
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Yes
No
Do you need assistance with grooming/personal hygiene?
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Yes
No
Notes
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Independent Living Daily Activities
(Does not apply for young children/school age children)
Do you need someone to fix/cook your meals?
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Yes
No
Do you need assistance with shopping?
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Yes
No
Do you need assistance with household chores?
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Yes
No
Do you need help with managing your money?
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Yes
No
Notes
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Equipment
Do you use any other kind of special equipment throughout the day? (wheelchair, rollator, walker, ect)
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Yes
No
Do you use any specialized equipment in the bathroom? (Shower grab bars, toilet bars, seat riser, shower chair)
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Yes
No
Do you require the use of incontinence wear?
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Yes
No
Notes
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Food Security
Do you have enough food in your home?
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Yes
No
Do you need assistance getting SNAP benefits or commodities?
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Yes
No
Are you unable to get food and supplies due to lack of mobility or transportation?
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Yes
No
Notes
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Self-Direction
Do you have to be reminded to dress, eat, bathe….?
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Yes
No
Do you need someone to coordinate your personal care?
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Yes
No
Are you aware of dangers around you?
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Yes
No
Notes
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Employment
Do you have gainful employment?
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Yes
No
Do you want gainful employment?
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Yes
No
Health Insurance
Do you currently have health insurance?
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Yes
No
Do you have prescription coverage?
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Yes
No
Do you have Medicare?
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Yes
No
Do you have Medicaid?
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Yes
No
Do you have private/commercial insurance?
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Yes
No
Notes
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House Modifications for Access
Do you currently use a wheelchair or suffer from a neurological or physical disability that prevents you from accessing your home?
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Yes
No
Do you need a bathroom modification? (Referrals will be given)
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Yes
No
Do you need a ramp for home access? (Referrals will be given)
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Yes
No
Do you need other home modifications for accessibility? (Referrals will be given)
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Yes
No
Notes
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Voting
Are you a registered voter?
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Yes
No
Would you like help registering to vote?
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Yes
No
The services I am requesting will help me: (Please check all that apply)
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Improve my ability to function in my family or community.
Maintain my ability to function in my family or community.
Obtain, maintain or advance in employment.
Any request for services or equipment is subject to approval and availability.
Upon approval you will be notified.
I give permission for TARP Center for Independent Living Grantors to view my files, if necessary.
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Yes
I certify all information is true and correct to the best of my knowledge.
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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.
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I Accept
ILS Signature
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Date
*
Submit
