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INITIAL INTAKE AND ASSESS M ENT TOOL -AMERICAN RELY CROSS -U.S. DEPARTMENT OF WEALTH ACID HUMAN SERVICES <br />HE.uRtNG <br />circle <br />AcUme to be tkkem <br />Cfomrnen -a <br />Do you use a heart ng aid and do you have is <br />''E3 : NO <br />If Yes to either, ask the next two <br />with you? <br />questions. <br />If No, skip next two questions. <br />15 the hearing aid working? <br />YES I NO <br />If No, identify potential resources <br />for replacement. <br />Do you need a bataery? <br />YES I NO <br />If Yes, identify poterflial resources <br />for replacement <br />Do you need a sign language interpreter? <br />YES.' NO <br />IF Yes, identify potential resources <br />in conjunction with shelter <br />manager. <br />How do you Crest communicate wi others? <br />Sign language? Lip read? Use a <br />TTY? Other (explain). <br />YIS'IONlSIGHF <br />Clrcla <br />Aa bo be taken <br />commen <br />Do you wear prescription glasses and do you <br />YES I NO1 <br />If Yes to either, ask next question. <br />have them with you? <br />If No, skip the next question_ <br />Do you have difficulty seeing, even with <br />YES I NO <br />If No, skip t a remaining <br />glasses? <br />Vision+Sighi questions and go to <br />Activities of Daily Living Becton. <br />Do you use a white cane? <br />YES I NO <br />If Yes, ask next question. <br />f skip she nexiquestion. <br />Do you have your white cane with you? <br />YES I NO <br />If No, identify potential resources <br />.`or replacement <br />Do you need assistance getting around, even <br />YES I NO <br />If Yes, collabtrra7e wih HIS and <br />with your white cane? <br />shelter manager. <br />ACTFJrIFIES OF MULY UVING <br />Circle <br />ABk adI qussMGna In ca o . <br />Corm onft <br />Do you need help getting dressed, bathing, <br />YES I NO <br />If "es, sperm y and expcain. <br />eat ng, toileting? <br />Do you have a family member, friend or <br />YES I NO <br />If No. consult shelter manager to <br />careg Iver with you to help with these activities? <br />determine if general population <br />shelter Is appropriate. <br />Do you need help mooring around or petting in <br />'ES I NO <br />If Yes, explain.. <br />and out of bed? <br />Do you rely on a mobility device such as a cane, <br />IES I NO <br />If No, skip the next question. If <br />walker, wheelchair or transfer board? <br />Yes, list <br />Do you have 'he mobility devicelequipment with <br />YES I NO <br />If No, identify potential resources <br />you? <br />for replacement <br />NUTFJTN]N <br />Clrsla <br />Aifflons to be taken <br />Celrinenta <br />Do you wear dentu res and do you have them <br />YES I NO <br />If needed, identify potendal <br />with you? <br />resources for replacement. <br />Are you. on any special diet? <br />YES I NO <br />If Yes, list special diet and notify <br />feeding staff. <br />Do you have any allergies to food? <br />YES I NO <br />If Yes, list allergies and notify <br />F � <br />feeding staff. <br />Queebm to htewlewef: Ha� Irp OE—sor X-f able to <br />"ES; NO <br />If No or Inch. ,DnsdtwO HS, OhIN <br />axpaess mailer needs and rnake mows <br />3Rd eroeeerrnanager. <br />gusetlon to Inte[VIONer. Cat DUE shelter p Ve' 1 Jte <br />YES. I NO <br />If Ns, aallabDate''AM HS and Mew <br />a651etaMce aria support needed <br />rnwagef on ammatlye melterng <br />options. <br />NAME OF PERSON. COLLECTING INFORMATION: <br />HS; DkIH Signatiue: <br />vale: <br />n. Y "wa6hbr,,.n low k- 1,relr•.url kr bu'n 4enn rantluri i'tl xl I'll vdlral i[NYnc[: . -a:k vx i[q..n rrw r,y eu, rn +,n -.. .1 1 ,........ i- ru,•ii: <br />,.. aI- IL F R H AL :hri, <br />wh: 7- f—" s nsri[e'E.-I Ci[ tvlknxq Y. nab. &.Hfl- —.F—, h4aLh[na v�trkm. m: <br />Inleau[{ r�io .e 'ale :vfirx rAT —inhe rmr. afl,do -i rifs>F!�ou aFi:n maotedwll[m.twinm _ tR.rh rspcs ...uxlr. :ra�y'asea :: <br />FkVftk l Ft of frimm <br />Cabarrus County EOP — Annex L — Shelter and Mass Care <br />In'18 IMIX. W1 mDrdmm hDN <br />Attachment number 12 <br />F -6 Page 287 <br />