LOCAL INTAKE ASSESSMENT - Section 16 - Daily Living Skills

Local Name

First Name

Last Name

Showers regularly without reminders

rate on a scale from 1-10

Brushes teeth regularly without reminders

rate on a scale from 1-10

Washes clothes regularly without reminders

rate on a scale from 1-10

Cooks independently

rate on a scale from 1-10

Cleans room regularly

rate on a scale from 1-10

Grocery shops independently

rate on a scale from 1-10

Identifies and communicates needs independently

rate on a scale from 1-10

Operates cleaning equipment independently

rate on a scale from 1-10

Verbal communication over the phone

rate on a scale from 1-10

Communication via text

rate on a scale from 1-10

Communication through reading/writting

rate on a scale from 1-10

Creates reminders independently for medication, appointments, etc.

rate on a scale from 1-10

Able to Access Transportation

rate on a scale from 1-10

Preferred methods of transportation

Drives own car

Bus

Door-to-door Via Bus

Ride Hail (uber/lyft)

Walking

Biking/skateboard/scooter/skates

Accesses and arranges transportation independently

rate on a scale from 1-10

Aware of surrounding when in public

rate on a scale from 1-10

Pedestrian safety

rate on a scale from 1-10

Skip to section: 1 2 3 4 5 6 8 9 10 11 12 13 14 15…17 18

SOUTHWIND FIELDS IS A NONPROFIT 501(C)3 ORGANIZATION