Self Assessment Tool

Care Plan Builder

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SELF ASSESSMENT

To help expedite your care needs, we offer this self assessment tool. This form is used instead of an in-person assessment where we can best match your desired needs to the skillset and personality of your caregiver.

Beacon Home Care ("we," "us") may need to share certain personal information to coordinate and deliver services, arrange payment, ensure quality and safety, or comply with law. This form lets you tell us what we can share, with whom, and why.

Why We Share (purposes)

Care coordination & continuity (updating care plans, scheduling, handoffs)

Payment & operations (eligibility, prior auth, billing, audits)

Quality, safety & compliance (training, supervision, incident review)

Referrals you request or authorize

Legal requirements (court orders, reportable conditions)

We do not sell your personal information. We do not share for third-party marketing without your separate written permission.

What We May Share (check all that apply)

Contact & demographics (name, address, phone, email)

Care-related details (care plan, service schedule, progress notes)

Health information/PHI relevant to services (diagnoses, medications, functional status)

Financial & billing information (payer, authorizations, invoices, claims)

Emergency & safety information (care alerts, fall risks, emergency contacts)

We will only share the minimum necessary information for the stated purpose.

Who We May Share With (check all that apply)

Health care providers involved in care (physicians, therapists, hospitals, pharmacies)

Payers and benefits administrators (Medicare/Medicaid, private insurance)

Care partners and referral sources (senior centers, case managers, placement agencies)

Technology/service vendors supporting our operations (e.g., scheduling, EHR, secure messaging), bound by contract to protect your data

Family Caregivers

Consent

I authorize Beacon Home Care to share my information as indicated above.

I do not authorize Beacon Home Care to share my information as indicated above.

ABOUT YOU

Your Name(Required)

First

Last

What event or series of events motivated you to reach out to Beacon Home Care?(Required)

How did you hear about us?

Internet Search

Referred by a Health Care Provider or Professional

Referred by a Facility or Community

Referred by a Family Member

Referred by a Friend

Referred by a Beacon Home Care Employee

Other

ABOUT CARE RECIPIENT

Care Recipient's Name(Required)

First

Last

What is your relationship to the Care Recipient?

Who does the Care Recipient live with?(Required)

Alone / Self

Husband / Domestic Partner Male

Wife / Domestic Partner Female

Son / Grandson

Daughter / Granddaughter

Other Relative(s)

Friend or Roommate

Facility or Community

Care Recipient's Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone

Height(Required)

Weight(Required)

Relationship Status(Required)

What is the primary language spoken?

What is the preferred language spoken?

Respectfully, are there any customs or traditions that we should be aware of?

What is the ethnicity of the Care Recipient?

What did the Care Recipient do as a profession?

Is the Care Recipient a veteran?

Is their any smoking inside the home of the Care Recipient?(Required)

Are there any pets in the home?(Required)

If yes, please specify the number and type of pets in the home?

Please specify type and quantity

FUNCTIONAL ASSESSMENT NEEDS

Is the Care Recipient alert and oriented?(Required)

Does the Care Recipient experience confusion or disorientation?(Required)

Can the Care Recipient be left alone?(Required)

Is the Care Recipient a fall risk, or have any concerns of falling?(Required)

Mobility(Required)

Walks independently

Walks with human assistance

Uses cane/walker

Uses wheelchair

Fall risk (Has had a fall, or a concern of a fall, within the past 6 months)

Bedbound

Transfers with slide table

Transfers with Hoyer lift

Type of Adaptive Equipment Available

Hospital Bed

Wheelchair

Cane

Walker

Electric Lift

Hydraulic Lift

Other

ADL NEEDS (Activities of Daily of Living)

Personal Care

Bathing

Dressing

Grooming

Toileting

Incontinence Assistance

Meals

Meal Preparation

Feeding Assistance

Special Diet

Hydration Reminders

Meal Instructions

List any special instructions or preferences (breakfast, lunch, dinner, snacks, etc)

Home Tasks

Light Housekeeping

Laundry

Linens

Trash

Plant Care

Pet Care

Errands and Transportation

Groceries

Pharmacy

Appointments

Social Outings

Companionship

Medication Reminders

Telephone Assistance

Conversation

Activities/Games

Supervision

MEDICAL INFORMATION

Allergies

Diagnosis or Impairment

Please provide a brief description

Please provide a brief summary of medical needs (Dementia, strokes, COPD, recovery, etc.). Please describe any medical assisted devices

ABOUT COGNITIVE ABILITY

Memory Loss(Required)

Yes, there are memory care needs

Yes, there are memory care needs and it's diagnosed by a physician

Unsure

If memory loss is diagnosed, specify common needs

Select All

Cueing

Redirection

Prevent Wandering

Sundowning Support

Please specify trigger agitations or soothers, if any

ABOUT SCHEDULING & START

Desired schedule(Required)

Mornings

Afternoons

Evenings

Overnights

24 hour or Live-in Care

Temporary Assignment(s)

Unsure

Coverage desired (per day)(Required)

2 hours

3-4 hours

5-6 hours

7-8 hours

8+ hours

Not Sure

Days per week desired(Required)

Select All

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Ideal Start Date and Time(Required)

ABOUT PREFERENCES

How would you best describe the Care Recipient's outlook on home care?(Required)

High outlook and total acceptance into receive care

Moderate outlook and openness of care

Low outlook and may have reservations about receiving care

Resistant to care. Does not want or feel the need for a caregiver

None. Does not know caregiving options are being explored

How would you best describe the Care Recipient's personality?(Required)

Select all that apply

Select Preferences(Required)

No Preference on Caregiver(s)

Prefers Female Caregiver(s)

Prefers Male Caregiver(s)

Female Caregiver(s) Only – No Exceptions

Male Caregiver(s) Only – No Exceptions

Must drive own car

Can drive client car

Multiple choice

What caregiver traits would work best with the Care Recipient's personality?(Required)

Select all that apply

SERVICE PROVIDERS

Are there other current service providers providing assistance?

Home Health

Hospice Care

Palliative Care

Physical Therapy (PT)

Occupational Therapy (OT)

Select all that apply

Is there a case manager involved with the Care Recipient's care?

If yes, list any private geriatric care manager, case manager NAME, COMPANY, and CONTACT INFO (if applicable)

PAYMENT

Private duty home care is not covered under any medical insurance, unless – there is a written order from a physician for outpatient Home Heath Care or Hospice Care.

Party Responsible for Payment

Enter name and contact information

Payment Options

Private Pay Cash or Check

Private Pay Credit Card

Long Term Care Insurance

VA Assistance

Other Grant Assistance

Workers Compensation Insurance Claim

EMERGENCY & ACCESS

Emergency contact (name/phone)

Additional Emergency contact (name/phone)

Home Access Notes

Please list any notes or special instructions about entering and exiting the home such as stairs, pets, etc.

HOW CAN WE REACH YOU?

We would love to chat with you. How can we get in touch?

Preferred Method of Contact

Best Time to Call You(Required)

Your Phone(Required)

Your Email Address(Required)

Email Address Confirm Email Address

Your Comments/Questions

Additional Attachments

Drop files here or

Max. file size: 50 MB.

Attach Photo of Bedroom

Drop files here or

Max. file size: 50 MB.

Attach Photo of Living Area

Drop files here or

Max. file size: 50 MB.

Attach Photo of Kitchen Dining Area

Drop files here or

Max. file size: 50 MB.

Attach Photo of Care Recipient's Main Bathroom

Drop files here or

Max. file size: 50 MB.