FAIL (the browser should render some flash content, not this).

Please CLICK HERE to download a PDF version of this form.


 

What is evaluated during an assessment process?

The online assessment provides valuable cognitive, functional and health information to those involved in care planning decisions.  It provides insightful feedback to choose the safest living environment for individuals.

Read each description carefully and choose the one that BEST FITS your situation. Complete the contact information above and when you have finished, click submit. Someone from LTS will contact you.



An assessment provides valuable information to families and long-distance caregivers who are involved in formulating safe and comprehensive care solutions for loved ones. 

The information can assist family members in reaching a consensus.



Online Assessment. Please fill out this questionnaire and click SEND.

Your Full Name:

 Your Phone Number
Your Email:
 City, State & Zip Code:
   
Living Situation/Safety
Loved one prefers to live independently in own home and/or live with relative; living situation is safe and he/she is able to arrange for assistance as needed.
Loved one needs some assistance to live independently; prefers to live in current location (home and/or neighborhood); needs someone periodically checking in.
Loved one requires continuous supervision; depends on others for all assistance; unable to safely be alone.
Health/Medical Situation
Loved one has minor health needs; is able to independently access community and physician resources; does not require frequent medical contact.
Loved one has moderate health needs, mild confusion, early signs of dementia or cognitive impairment; needs ongoing physician contacts to monitor chronic medical concerns; requires assistance with medication management.
Loved one afflicted with long-term medical condition or disability, exhibits signs of dementia or cognitive impairment including confusion, wandering; has had frequent or recent hospitalization (s); requires continuous medical help; depends upon others for medication management.
Functional/Mobility
Loved one ambulates independently and/or safely (either with or without assistive devices); uses telephone independently; able to provide for personal care needs (bathing, dressing etc); does not need daily supervision or regular contacts.
Loved one is mobile in own living area yet needs assistance in unfamiliar areas such as going to appointments; needs periodic help with personal care (bathing, dressing etc.) less than three times a week; needs daily supervision or regular contacts.
Loved one is unable to ambulate or transfer safely without assistance or supervision; needs safe environment with emergency call system; unable to provide for personal care needs (bathing, dressing etc); depends on others completely.
Insurance/Finance
Loved one has adequate health and long term care insurance coverage; is aware of all benefits (public and private); knows how specific benefits pay in certain healthcare situations.
Loved one has adequate health insurance for catastrophic medical needs, lacks long term care insurance coverage and somewhat familiar with how to use current insurance; needs help in managing insurance, payments and claims.
Loved one is unaware or can not manage insurance or finances; requires someone else to make decisions; unsure of insurance options.
Support and Services
Loved one has family or others available to provide emotional support; can manage or arrange for household chores such as housekeeping, laundry and shopping; has adequate social contacts.
Loved one requires some assistance to cope with emotional needs; unable to arrange for housekeeping, laundry and shopping services; infrequent social contacts.
Loved one requires ongoing oversight to cope with emotional needs; requires crisis intervention for inappropriate, uncooperative, abusive behavior; depends on others for all household chores; socially isolated.

 
 

 
 

 

HomeAbout us LTCI Claims LTCI Underwriting IndividualsCorporationsProviders Contacts

2007-2008 © Copyright Long Term Solutions, Inc.. All rights reserved. Read Privacy policy.