Attention all Parishoners Providing Care and Assistance To
 or Receiving Care or Assistance From Another Individual
As the number of elderly individuals in our society increases, statistics show that many more individuals are now providing some sort of care or assistance to another than ever before. Many services are available to make this easier on both the individual giving and the individual receiving care. Members of the health ministry are attempting to determine what services would be helpful to the medically or mentally challenged members of our community, the frail elderly, and those who provide care or assistance to them.

The following needs assessment is designed to assist us in collecting the appropriate information to adequately inform us to better serve the needs of these individuals within the St. Francis Community. We are asking that anyone who is giving care or assistance to or receiving care or assistance from another take a couple of minutes to respond to the following questions in the space provided.

Your answers on this form are anonymous.  After you complete it, you'll be given a separate opportunity to contact us with questions or requests.

Thank you,
St. Francis Health Ministry

 Caregiver Needs Assessment

 Check each statement which applies to you:

I provide care or assistance for another person.
I receive care or assistance from another person.
That person lives with me.
That person is a family member.

How many hours per day do you provide/ receive care?
How many days per week do you provide/ receive care?

 What does that care include? Check all that apply:
Feed/cook for
Bathe
Dress
Assist with walking
Provide toilet assistance
Shop for
Provide transportation
Housekeeping
Laundry
Help with medications
Help manage financial affairs
Help find services
Help with screening such as blood pressure, blood glucose
  Would respite care be helpful to you? Yes / No

  If so, how many hours per week would you use respite care? 
 

The American Red Cross has developed a fairly comprehensive series of caregiver training courses, and we plan to offer them to our parishioners in the near future. If you are a caregiver or family member who might be interested in these courses, please mark the time of day and days of the week that would be the easiest for you to attend. We will try to find instructors who can accommodate the responses we receive.
Morning Afternoon Evening

Weekday Weekend

 Assessment for person requiring extra help:
 Check which assistance you need:
Meal preparation
Provide transportation
Housekeeping assistance
Laundry
Help with medication set-up
Help with financial planning
Small household fix-ups
Grocery shop
Take shopping

What other assistance would be of benefit to you? 


Your answers on this form are anonymous.  After you complete it, you'll be given a separate opportunity to contact us with questions or requests.