Wisconsin Family Caregiver Support Programs Caregiver ...



DEPARTMENT OF HEALTH SERVICESDivision of Public HealthF-02519 (11/2022)STATE OF WISCONSINPage PAGE \* Arabic \* MERGEFORMAT 1 of NUMPAGES \* MERGEFORMAT 2WISCONSIN FAMILY CAREGIVER PROGRAMNEEDS ASSESSMENTCaregiver NameCaregiver ID NumberDate FORMTEXT ????? FORMTEXT ?????Enter DateCare Recipient Name FORMTEXT ?????SECTION I: Unmet Care Recipient Needs (Check all of the items needs help with)Adaptive Equipment?Yes ?NoManaging Health Care?Yes ?NoBathing?Yes ?NoMentally Stimulating Activities?Yes ?NoDressing?Yes ?NoMoney Management?Yes ?NoCompanionship?Yes ?NoNutritional Counseling?Yes ?NoCooking?Yes ?NoOvernight Care?Yes ?NoDementia Care Specialist Referral?Yes ?NoPersonal Emergency Response System?Yes ?NoEating?Yes ?NoShopping?Yes ?NoElder Benefits Counseling?Yes ?NoSupplemental Nutrition Assistance Program (FoodShare) ?Yes ?NoGrooming?Yes ?NoToileting?Yes ?NoHome Delivered/Congregate Meals?Yes ?NoTransferring?Yes ?NoHome Modifications?Yes ?NoTransportation?Yes ?NoIn Home Safety/Security?Yes ?NoOther: FORMTEXT ??????Yes ?NoIncontinence Strategies?Yes ?NoDoes not apply?Yes ?NoInteraction with Others?Yes ?No?Yes ?NoTop needs identified by caregiver: FORMTEXT ?????Note: Sections II through V Refer to the Caregiver’s Needs, not the care recipientSECTION II: Unmet Caregiver Respite Needs (Check all that you need more time for or help with)Free Time to Oneself?Yes ?NoOutside Chores?Yes ?NoHousecleaning?Yes ?NoOvernight Respite?Yes ?NoLaundry?Yes ?NoPreparing Meals?Yes ?NoMaking/Keeping Appointments?Yes ?NoShopping?Yes ?NoManaging Your Own Medications?Yes ?NoTransportation?Yes ?NoMeeting Employment Obligations?Yes ?NoOther: FORMTEXT ??????Yes ?NoMoney Management?Yes ?NoDoes not apply?Yes ?NoTop needs identified by caregiver: FORMTEXT ?????SECTION III: Unmet Caregiver Physical Health Needs (Check all that you need or would you benefit from)Access to Affordable Health/Dental?Yes ?NoNutritional Counseling?Yes ?NoExercise?Yes ?NoPowerful Tools for Caregivers?Yes ?NoFood Pantries?Yes ?NoShopping Access/Transportation?Yes ?NoFree Time to Oneself?Yes ?NoSupplemental Nutrition Assistance Program (FoodShare)?Yes ?NoHelp Preparing Balanced Meals?Yes ?NoOther: FORMTEXT ??????Yes ?NoHome Delivered Meals?Yes ?NoDoes not apply?Yes ?NoMore Sleep?Yes ?No?Yes ?NoTop needs identified by caregiver: FORMTEXT ?????SECTION IV: Unmet Caregiver Emotional Health Needs (Check all that apply)How have you been handling the emotional stress of caring for _______? Has it been difficult emotionally?Are you able to handle the added stress from caring for ________?Are you aware of support groups/memory cafés and that counseling and support groups are available?Family Meeting?Yes ?NoPeople Willing to Help?Yes ?NoFree Time to Oneself?Yes ?NoSocial Time with Family/Friends?Yes ?NoMemory Café?Yes ?NoStress Relief/Relaxation Techniques?Yes ?NoMental Health Counseling?Yes ?NoSupport Group?Yes ?NoOptions Counseling/Resources?Yes ?NoOther: FORMTEXT ??????Yes ?NoPaid Respite?Yes ?NoDoes not apply?Yes ?NoParticipate Activities Outside Caregiving?Yes ?No?Yes ?NoTop needs identified by caregiver: FORMTEXT ?????SECTION V: Education and Resource Needs (Check all that apply)Are advance directives in place for your loved one? For yourself? Would more information or education about handling behavior challenges or the person’s condition, caregiving stress or community resources be helpful?Advanced Directive/Power of Attorney?Yes ?NoOptions Counseling/Resources?Yes ?NoAlzheimer’s 24/7 Helpline?Yes ?NoPowerful Tools Workshop?Yes ?NoClarify End-of-Life Wishes?Yes ?NoShare the Care Program?Yes ?NoDe-escalation Techniques?Yes ?NoSupport Group?Yes ?NoHealth Care Literacy?Yes ?NoTrualta Online Caregiver TrainingOther: ?Yes ?No?Yes ?NoInformation about Disease Progression?Yes ?NoDoes not apply?Yes ?NoLong-Term Planning?Yes ?NoTop needs identified by caregiver: FORMTEXT ?????Conversation StartersQuestions to help caregivers identify their most important needs. (Responses from this section are not reported to DHS)What two situations/responsibilities are the most stressful for you? FORMTEXT ?????How could these situations be eliminated/reduced or made less stressful? FORMTEXT ?????If you could remove one responsibility from your daily or weekly routine to make life easier, what would that be? FORMTEXT ?????What techniques do you currently use to relieve stress? FORMTEXT ?????Who can you rely on to give you a break from your responsibilities? FORMTEXT ????? ................
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