Membership Assessment Form Name * First Name Last Name Phone * (###) ### #### Email Mobility * Requires transport assistance Yes No Toilet Needs * Requires assistance with toileting Yes No Nutrition * Requires assistance when eating and/or is fully dependent on others for nutrition Yes No Medications * Cannot administer medications without reminders and/or assistance Yes No Cognition * Orientation, memory, and judgment skills are impaired and/or diagnosis of Alzheimer's and/or dementia Yes No Behavior * Requires assistance with coping, stress, or other emotional issues and/or requires monitoring at all times Yes No Hygiene * Requires assistance for bathing and dressing Yes No If you have answered YES to any of these questions, you may not be eligible for membership. Please contact us at 804-664-4483 for further information.
