Enhanced Care Management (ECM) Comprehensive Assessment

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* 7. Who do you live with? (check all that apply)

Live Alone

Live with spouse or significant other

Live with children or other relatives or friends

Live with caregiver

Live with other residents in my facility/program

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* 8. How often do you see or talk to people that you care about and feel close to? (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)

Less than once a week

One or two times a week

Three to five times a week

Five or more times a week

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* 9. Are you caring for anyone and/or any pets?

Yes, and their name(s) and relation to me are:

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* 10. Over the past month (30 days), how many days have you felt lonely? (Check one.)

None—I never feel lonely

Less than five days

More than half the days (more than 15)

Most days—I always feel lonely

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* 11. Do you have family members, friends, or others willing to help you when you need it?

Yes

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* 12. Do you have a caregiver assisting you?

Yes, and his/her name, email, and phone number are:

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* 13. Do you ever think your caregiver has a hard time giving you all the help you need?

Yes, and here's why:

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* 14. Do you have an In-Home Supportive Services (IHSS) worker?

Yes

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* 15. My income is from the following sources (check all that apply):

CalFresh benefits (SNAP)

TANF recipient

SSI recipient

SSDI recipient

SSA (retirement) recipient

Other retirement income

Employed

VA Benefits

General Relief

None of the above

Other (please specify)

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* 16. What is your total monthly income from your combined sources?

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* 17. What is your current work situation? (check all that apply)

I am employed part-time

I am emplyed full-time

I have unpredictable employment (for example. day labor)

I am a student

I am Retired

I volunteer or earn benefits from a long-term care and support or, rehab Center

I volunteer or earn benefits from Family PACT

I volunteer or earn benefits from Community-Based Adult Services

I volunteer or earn benefits from the Veterans Administration

I volunteer or earn benefits from Palliative care programs

I volunteer or earn benefits from a Regional Center

I volunteer or earn benefits from California Children’s Services

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* 18. Are there any concerns or challenges with your job?

Yes, my concerns include:

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* 19. In the past 12 months, have you been involved with the following (check all that apply):

Court ordered services

On probation

On parole

Re-entry program

DUI/restricted license

Adult Protective Services (APS) or Child Protective Services (CPS)

Community Legal Services

None of the above

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* 20. In the past year, have you spent more than two nights in a row in a jail, prison, detention center, or juvenile correctional facility?

Yes

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* 21. Have you ever associated with members of a gang or been involved in one?

Yes, but I am no longer involved

No, I was never involved

Yes, and I am still slightly involved

Yes, and I am still heavily involved

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* 22. Do you have a will, trust, life-planning document or advance directive in place?

Yes

No, but I would like more information on these topics

Enhanced Care Management (ECM) Comprehensive Assessment - Section F

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* 1. Today's Date

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* 2. First Name

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* 3. Last Name

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* 4. Date of Birth

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* 5. Email

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* 6. SMS Text

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* 7. Who do you live with? (check all that apply)

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* 8. How often do you see or talk to people that you care about and feel close to? (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)

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* 9. Are you caring for anyone and/or any pets?

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* 10. Over the past month (30 days), how many days have you felt lonely? (Check one.)

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* 11. Do you have family members, friends, or others willing to help you when you need it?

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* 12. Do you have a caregiver assisting you?

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* 13. Do you ever think your caregiver has a hard time giving you all the help you need?

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* 14. Do you have an In-Home Supportive Services (IHSS) worker?

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* 15. My income is from the following sources (check all that apply):

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* 16. What is your total monthly income from your combined sources?

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* 17. What is your current work situation? (check all that apply)

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* 18. Are there any concerns or challenges with your job?

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* 19. In the past 12 months, have you been involved with the following (check all that apply):

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* 20. In the past year, have you spent more than two nights in a row in a jail, prison, detention center, or juvenile correctional facility?

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* 21. Have you ever associated with members of a gang or been involved in one?

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* 22. Do you have a will, trust, life-planning document or advance directive in place?