"It is not how much you do, but how much love you put into the doing" - Mother Teresa

2156 Edgewood Circle SE, Olympia, WA 98501
1805 Centerwood Drive SE, Olympia, WA 98501

Phone: 360.338.8601
Fax: 360.515-5690
Email: treeoflifehomesafh@gmail.com

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I would like to invite you to our homes. With over 28 years of caregiving and healthcare administration experience, I dreamed of one day welcoming elderly residents to these special homes.
Drop by during business hours, or give me, [Owner Name] (owner / administrator) a call to schedule an appointment at 206-355-5643
Assessment Form - Tree of Life Homes

Assessment Form

Comprehensive Care Assessment for Tree of Life Homes

How to Complete the Form

Online: For most people this form is easiest completed online. Simply fill-in the form on your screen then click the "Submit by Email" button and follow the instructions.

By mail or fax: If you have a printer attached you may print out the form first, hand write your answers, and either mail or fax back to us.

Please complete the information as best you can as it will help us in providing a more accurate estimation of the cost of care.

Basic Information

About the Resident

About You

Medical

Financial

Activities of Daily Living

ADL General

Activity No Help Needed
/Independent		 Some Help
Needed		 Extensive
or Total Help
Dressing: Upper Body
Dressing: Lower Body
Hygiene: Hands & Face
Hygiene: Hair, Teeth, Make-up, Shaving
Hygiene: Using Toilet/Incontinence Issues
Hygiene: Bathing or Showering
Mobility: Getting in or out of Bed/Chair
Locomotion: Needs Help w/Chair or Walking
Dining: Set Up/Cutting Up Food
Dining: Eating and Self Feeding
Bed Mobility: Turning and Positioning in Bed

Bowel & Bladder Function

Function No Help Needed
/Independent		 Some Help
Needed		 Extensive
or Total Help
Bowel: Continence Needs
Urinary: Continence Needs

Mental & Cognitive Status

Note: This includes things like being disruptive, agitated or aggressive, abusive, demanding and/or requiring frequent staff intervention. Is the resident delusional or does he/she have hallucinations? Please describe the resident's emotional status, personality, and demeanor:

Other Items

Care Need No Help Needed
/Independent		 Some Help
Needed		 Extensive
or Total Help
Require injections
Blood Glucose Monitoring
O2 Therapy
Needs Night Care

Thank you for taking the time to complete this questionnaire. The guide you will receive is approximate and based on the information you provided above. A more accurate cost quote can be given after a comprehensive assessment by Tree of Life Homes has been carried out.

"I would like to invite you to our homes. With over 38 years of caregiving and healthcare administration experience, I dreamed of one day welcoming elderly residents to these special homes."

Drop by during business hours, or give us a call to schedule an appointment.

Submitting your assessment...

* Required fields

❝
I would like to invite you to our homes. With over 28 years of caregiving and healthcare administration experience, I dreamed of one day welcoming elderly residents to these special homes.
Drop by during business hours, or give me, [Owner Name] (owner / administrator) a call to schedule an appointment at 206-355-5643

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