Care Coordination Discovery Form

Discovery Assessment

Please complete this form to help us understand your situation to best seek appropriate resources.

? Identify the Primary Client

I am a Caregiver Complete Sections 1 - 5

I am the Client Complete Sections 2 - 5 Only

SECTION 1: Client Engaging in Services (Caregiver)

1a. Client Information

Date of Birth

Are there other family members involved in his/her care?

Yes No

1b. Current Challenges

Check all that apply:

Lack of direction or purpose In need of resources Stress or overwhelm Career/education uncertainty Work/life imbalance Declining health/wellness Financial stress Relationship strain

Are there other family stressors or challenges impacting you and the family?

Tell me more about your current situation and responsibilities separate from your caregiver role (marriage, children, community):

Do you work outside of the home? If so, what does this look like?

What are your current caregiving responsibilities on a daily/weekly/monthly basis?

1c. Support & Resources

What are you doing for your own wellbeing? (fitness, hobbies, social engagement outside of client support). What would you like to do more of? Less of?

Are there areas you feel would benefit from more organizational systems?

What services have you received in the past?

Type	Past	Current	Interested
Alternative Therapies
Mental Health Therapy
Respite
Coaching

SECTION 2: Family Member Information

Date of Birth

Diagnosis Information

Date / Year of Diagnosis

Primary Category

Specific Diagnosis

Secondary Category

Specific Diagnosis

Have symptoms changed recently?

Yes No

Rehab / Treatment Activities:

Type	Past	Current	Interested
Physical Therapy (PT)
Occupational Therapy (OT)
Speech Therapy (SLP)
Recreational Therapy
Alternative Therapies
Mental Health Therapy

2c. Current Challenges (Family Member)

What challenges does the person you are caring for face because of their current health status?

How do these challenges impact you and your other family members?

2d. Supports & Resources (Family Member)

What supports are currently in place to support your loved one? (Home health, friends, church, etc.)

What organizational tools or systems (if any) are in place related to caregiving?

What were some of their interests/hobbies prior to their injury?

What interests/hobbies have they engaged in post-injury? Any barriers?

Do they currently work or have they in the past worked with any organizations to support these interests?

SECTION 3: Goals & Expectations

What are your short and long term goals for yourself?

What are your short and long term goals for family member?

Clarify and confirm - What are you hoping to gain from supports with Ellipses?

Discovery Assessment

? Identify the Primary Client

SECTION 1: Client Engaging in Services (Caregiver)

1a. Client Information

1b. Current Challenges

1c. Support & Resources

SECTION 2: Family Member Information

Diagnosis Information

2c. Current Challenges (Family Member)

2d. Supports & Resources (Family Member)

SECTION 3: Goals & Expectations

SECTION 4: Logistics & Legal

Insurance / Benefits

SECTION 5: Needs Assessment & Recommendations

Areas of Goal Planning

Engagement

Mind

Physical Health & Wellness

Resources