checked />Abusive Relationship(s) checked />Behavioral Problems checked />cant Afford Medications checked />Caregiver unable to provide Care checked />Confusion checked />Dependent on others checked />Depression checked />Excessive Spending checked />Health Problems checked />Lives Alone checked />No Insurance checked />Poor Family/Social Support checked />Potential for Financial Abuse checked />Potential for Theft checked />Socially Isolated checked />Unable to Managefinances checked />Unable to Meet Expenses checked />Vision Deficit checked />Other

checked/>Lives Alone checked/>Lives at Home checked/>Lives in Foster Care checked/>Lives in Group Home checked/>Lives in Nursing Home/Assistive Living Facility checked/>Lives with Child checked/>Lives with Friend checked/>Lives with Sibling checked/>Lives with Spouse checked/>Other

checked/>Anxiety checked/>Behavioral Problems checked/>Confused checked/>Depressed checked/>Disoriented checked/>Grieving checked/>Guilt Feelings checked/>Inability to Cope checked/>Irritable checked/>Lethargic checked/>Moodiness checked/>Withdrawn checked/>No Mental/Emotional Issues Noted checked/>Other

checked/>Inadequate Heating and /or Cooling checked/>Inadequate Refrigeration checked/>Inadequate Sanitation and /or Plumbing checked/>Inadequate Smoke Detectors checked/>O2 in use without Precautions checked/>Presence of Insects and/or Rodents checked/>Rugs, Cords and/or Furniture causing Safety Risk checked/>Unsafe Appliances checked/>Unsafe Stairs and/or Doorways checked/>No Home Safety Issues Noted checked/>Other

checked/>Abusive Relationship(s) checked/>Communication Difficulties in Family checked/>Concurrent Life Crisis checked/>Dependent on Others checked/>Family Conflict/Discord checked/>History of Mental or Emotional Illness checked/>History of Substance Abuse checked/>Recent and/or History of Significant Loss checked/>No Risk Noted checked/>Other

checked/>Family/Friends unable to provide Care checked/>Family/Caregiver with Legal/Social/Mental/Medical Issues checked/>No Caregiver Contingency Plan checked/>Relationship Problems checked/>Socially Isolated checked/>Weak Social Support checked/>No Support Issues Noted checked/>Other

checked/>Medical Issues checked/>Mobility Limitation checked/>Needs Assistance with ADLs checked/>Speech Limitation checked/>Hearing limitation checked/>Communication Limitation checked/>Terminal Illness checked/>No Phycial Assessment Issues Noted checked/>Other

checked/>No Current Spiritual Provider checked/>Unresolved Spiritual Issues/Concerns checked/>No Spiritual Issues Noted checked/>Not Applicable checked/>Other