GOALS & NEEDS CHECKLIST
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- Anastasia Richards
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1 GOALS & NEEDS CHECKLIST Use this list to start the conversation about what is most important to your loved ones and what strengths they bring to bear. Goals Strengths To remain healthy and active To stay/move near family To remain in my own home for as long as possible To stay active with religious or community groups To maintain hobbies To be around people Great negotiator Adequate savings Low-maintenance single story home Large network of friends Close relations with family Other To move to a residence with support services Other Needs First determine if there is an immediate need under each area. If there is not a pressing issue, prioritize the tasks to be addressed and develop a timeline. 23
2 GENERAL NEEDS ASSESSMENT (One for each individual who will need care) Area of Need Types of Possible Tasks Point Person Home Maintenance and Living Situation Pay rent/mortgage Home repairs Ongoing maintenance Safety concerns Grocery shopping & meal preparation Lawn care Pet care Housekeeping Research alternative living arrangements Other: Financial Affairs Paying bills Keeping track of financial records Managing assets Applying and supervising public benefits programs Transportation Needs Driving decisions Coordinating rides Locating transportation services Personal Care Organization of family and professional care providers Help with daily grooming and dressing Rides to hair stylist Clothes shopping 24
3 GENERAL NEEDS ASSESSMENT (One for each individual who will need care) Area of Need Types of Possible Tasks Point Person Health Care Determine medical or emotional problems Make, accompany, drive or make alternate logistic arrangements for doctor s appointments Submit medical insurance and bills Explain medical decisions Medication management (fill prescriptions, fill pill boxes, give reminders, and dispense medications) Perform medical tasks (wound care, injections, and catheter) Communications Keeping family caregiving team informed Coordinating team visits Daily check in Socialization Sending greeting and thank you notes Arranging for visitors Arranging outings Adaptive Devices Ordering, maintaining, and paying for adaptive devices (e.g., wheelchair, walker, etc.) Training on how to use devices Other: 25
4 PERSONAL INFORMATION CHECKLIST (One for each individual who will need care) NAME X Personal Information Where is it kept? Contact Name (attach copy of documents) Social Security Card Birth Certificate Marriage Certificate Death Certificate (for Deceased Spouse) Divorce Papers Military Records Branch of Service VA ID#: Discharge Papers: Driver s License/Organ Donor Card Passport/Citizenship Papers Address Books (names and addresses of friends and colleagues) Lists of church & community memberships and contact information Information on waiting lists or contracts with retirement communities or nursing homes Information on funeral arrangements Pet Care: Vet, Sitter, Walker Beautician/Barber Lawyer Other Passwords 26
5 HOME MAINTENANCE CHECKLIST X Home Item Where is it kept? Contact Name (attach copy of documents) Mortgage Company Name: Amount due: Rental Management Company: Amount due: Rental/Real Estate Agent: Gas/Electric/Water Company: Cable/Internet/Telephone: Homeowners Insurance Agent: Insurance Policy #: Homeowners Premium: Garbage Service Garbage Pickup Day is: M T W Th F (circle) Home Services: Handy person Lawncare Appliances Passwords Computer(s) password clue(s) Phone messages password clue 27
6 HEALTH CHECKLIST PHARMACY Name PHONE # LOCATION PHARMACY Name PHONE # LOCATION DOCTOR Name PHONE # DOCTOR Name PHONE # DOCTOR Name PHONE # DOCTOR Name PHONE # DENTIST Name PHONE # HOME CARE AGENCY PHONE # 28
7 HEALTH CHECKLIST (continued) X Item Where is it kept? Contact Name Medicare Original or Medicare Advantage (company name): ID Number: Medicare Prescription Drug Coverage (company name): ID Number: (does not apply to an Advantage plan with drug coverage) Other Health Insurance Policy (Medigap): Company: Premium: Payment schedule: Veteran s Health System: ID #: Do Not Resuscitate (DNR) Order: POLST form-if available in your state Living Will Durable Power of Attorney for Health Care 29
8 MEDICATION CHART Prescription Name Strength Dosage Warnings/Instructions 30
9 TRANSPORTATION CHECKLIST NAME X Item Notes Where is it kept? Auto(s): Make(s): Auto Loan Information: Model(s): Title for Car(s): Auto Insurance Company: Recreational Vehicles: Title: Insurance: 31
10 FINANCIAL CHECKLIST X Item Where is it kept? Contact Name Bank Records (checking/savings accounts) Pin number clues online banking and accounts with passwords and clues Trusts Will Durable Power of Attorney for Finances Any rental agreements or business contracts Complete list of assets & debts List of routine household bills Federal & State Tax Returns (past 3-5 years): Tax Preparer: Records of any personal loans made to others: Financial Planner or Broker: Life Insurance Policy or Policies: Disability Insurance (long- and short-term): Long-Term Care Insurance: Safe Deposit Box(es): Location(s): Number(s): Keys: 32
11 PUBLIC BENEFITS CHECKLIST Your loved one may have or be eligible for help with paying for food, heating bills, property taxes and more. Use AARP BenefitsQuickLINK, to find out about programs in your state. X Item Food Assistance, (i.e., SNAP/FNS) YES NO Low Income Home Energy Assistance (LIHEAP) YES NO Supplemental Security Income (SSI) YES NO Property Tax Assistance YES NO Extra Help Paying for Medicare Part D (prescription drug coverage) YES NO Medicare Parts A, B and D Premium Support YES NO Medicaid (help with long-term care and medical care) Number & Identification Card YES NO Transportation Assistance YES NO 33
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