Laserfiche WebLink
INrrIAL INTAKE AND ASSESSMENT TOOL - AMERICAN RED CROSS -U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES <br />Dateffime Shelter Nam@Xity)State: DROName.%: <br />Family Last Name: <br />Does the family need language <br />Primary language spoken in home: assistanceJnterpreter ?: <br />Name wages .tgenders of all family members present: <br />If along and urdar i&.. Ioa.mflcn of—taf kln.'pamml'guardlan: If unknaren, w" crofter managm S Inters Ic IntHil hone: <br />Home Address: <br />Client Contact Number Interviewer Name lorint name : <br />INFFIAL NTAKE <br />Circle <br />Adlonls to be taken <br />Include ONLY name of arrec ed laml ly <br />mentor <br />1. Do you need assistance hearing me? <br />YES I NO <br />If Yes. consult wfth Disaster <br />Health Services (HS). <br />2. Will you need assistance w#th <br />YES I NO <br />If Yes, not fy shelter manager <br />anderstanding or answering these uesdons? <br />and refer to HS. <br />3. Do you have a medical or health concern or <br />YES I NO <br />If Yes, stop inbarvi.ew and refer <br />need right now? <br />to HS immediately. If life <br />threatening, call 911. <br />4. Observation for the Interviewer. Does. <br />YE-T NO <br />If life threatening, call 911. <br />the client appear to be overwhelmed. <br />If yes, or unsure, refer <br />disoriented, agitated, or a threat to self or <br />immediately to HS or Disaster <br />others' <br />Mental Health (DMH). <br />5. Do you need medicine. equipment Or <br />YES I NO <br />If Yes. refer to HS. <br />electricity to operate medical equipment or <br />other items for laity living? <br />6. Do you normal ly need a caregiver, pers"al <br />YES I NO <br />If Yes, ask next question. <br />assistant, or service animal? <br />If No, skip next question. <br />7. Is your caregiver, personal assistant or <br />YES I NO <br />If Yes, circle which one and <br />service animal inaccessible? <br />refer to HS. <br />S. Do you have any severe environmental, <br />YES I NO <br />If Yes, refer to HS. <br />food, or medication allergies? <br />9. Question to Interviewer: Would this <br />YES I NO If Yes. refer to HS or DMH. "If client is uncertain or unsure <br />person benefit from a more detailed health <br />of answer to any question, refer <br />or mental health assessment? <br />to HS or DMH for more in -depth <br />evaluation. <br />REFER tg: HE Ifell- No DMh YfiS No Interviewer inmal <br />DISASTER HEALTH SERVICESIDISASTER MENTAL <br />HEALTH ASSESSMENT FOLLOW -UP <br />- 4SSI3TAN d;E ANG SUPPORTINEOR1d.ATKYN <br />Curia <br />Actlons to be taken <br />Cormnenta <br />Have you b_en hose .a zed or under the cage of a <br />°'ES d NO <br />I`, 'Tea, Ii Ft reason. <br />physician in t­ aastrrcnth? <br />Do you have a carcitton that requires any special <br />YES 1 NO <br />It Yes, list potential sources i <br />medical equ pment}supplies? IEpi -pen, diabetes <br />available. <br />supplies, respiratw, oxygen, dialysis, ostomy <br />supplies, etc-) <br />Are you presently receanng any benefits <br />YES I NO <br />If Yes, list type and benefit <br />(Medicare,Medicaid't a do you have other hea th <br />nu mber(s) I available. <br />ns "vra,: ce coverage? <br />RIM CATIONS <br />Circia <br />Actions to off taken <br />Commanta <br />Do you take any medication (s) regularly? <br />YES NO <br />It No, skip to the questions <br />regarding hearing. <br />When did you last to ke you+ medioation? <br />Catejrrlme- <br />When are you d,.e fc­ ye rnext dose? <br />CatefTime_ <br />Do you have the medications vi rth You? <br />YES 1 NO <br />I` No, identify medications and <br />process for replacement <br />Rcrr w hF ci rr7_t9e <br />Cabarrus County EOP — Annex L — Shelter and Mass Care <br />InN. In ke antl M1a ,na Tod <br />Attachment number 12 <br />F -6 Page 286 <br />