Client Information Client # Agency: Access Network Client: Yes No Case Manager: Initial Assessment Date: _____________ Date of Birth: Race Employment Status African American Currently Working Zip Code: Caucasian Retired Asian American Unemployed Gender: Native American Seeking Employment Female Other: SCSEP/Older Worker Program Male Ethnicity Hispanic/Latino Marital Status Single Chronic Disease: Yes No Married Did you receive tax preparation assistance? Separated If yes, what:_______________ Yes No Widowed _________________________ Divorced _________________________ Total Dependents: #:______ Living with partner Housing Status Household Composition Health Insurance Own Home Living Alone Yes No Homeowner w/o Mortgage If yes, what? Living in a Household of 2 Homeowner w/ Mortgage Medicare (includes senior) Renter Unsubsidized Medicaid – Living in a Household of 3+ Renter Subsidized Private Insurance – (includes senior) Live w/ Others Medicare Advantage Homeless/Shelter Supplement? Reverse Mortgage Medigap Financial Exploitation Health Status Have you been a victim? Yes No Excellent Very Good Have you received info? Yes No Good Fair Filed a case with APS? Yes No Poor Check all that apply: Rent/Housing Situation Check all that apply: Credit Situation Monthly Financials (for Household) – Does the client have a bank account? Yes No Has client used retirement before 59½? Yes No
Client Information Client # Agency: Access Network Client: Yes No Case Manager: Initial Assessment Date: _____________ Date of Birth: Zip Code: Gender: Female Male Chronic Disease: Yes No If yes, what:_______________ _________________________ _________________________ Race African American Caucasian Asian American Native American Other: Ethnicity Hispanic/Latino Did you receive tax preparation assistance? Yes No Total Dependents: #:______ Employment Status Currently Working Retired Unemployed Seeking Employment SCSEP/Older Worker Program Marital Status Single Married Separated Widowed Divorced Living with partner Housing Status Own Home Homeowner w/o Mortgage Homeowner w/ Mortgage Renter – Unsubsidized Renter – Subsidized Live w/ Others Homeless/Shelter Reverse Mortgage Household Composition Living Alone Living in a Household of 2 (includes senior) Living in a Household of 3+ (includes senior) Health Insurance Yes No If yes, what? Medicare Medicaid Private Insurance Medicare Advantage Supplement? Medigap Financial Exploitation Have you been a victim? Yes No Have you received info? Yes No Filed a case with APS? Yes No Health Status Excellent Very Good Good Fair Poor Check all that apply: Rent/Housing Situation Check all that apply: Credit Situation Monthly Financials – (for Household) Does the client have a bank account? Yes No Has client used retirement before 59½? Yes No
Client-Assessment-and-Follow-up-Template.docx