Mae’s Grace Home Assessment

Calm, complete care planning for a safe first shift.

This assessment is designed to understand what is happening, what kind of support would bring relief, and whether Mae’s Grace can safely and respectfully help. It captures daily routines, safety, family communication, caregiver fit, authority, and first-week priorities.

Internal use: This form may include sensitive care information. Submit only through a secure Mae’s Grace website workflow. Do not use third-party form processors unless approved for sensitive client information.

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Client and assessment details

Start with the basic information needed to identify the client, family contact, and assessment context.

Client full name *

Assessment date *

Client city / ZIP *

Assessment completed by

Primary family contact *

Primary contact phone *

Primary contact email

Relationship to client

Opening notes

Why help is needed now

Understand the trigger, family concern, and what relief should look like after the first week.

What has changed recently that made additional help feel needed now?

Was there a specific event that triggered this conversation?

Fall Hospital stay Caregiver burnout Hygiene concern Memory change Safety issue Discharge planning Other

What is the family most worried could happen without support?

What has been hardest for the family so far?

What would make the family feel relieved after the first week of care?

Family goals and expectations

Clarify what success looks like and identify unrealistic or out-of-scope expectations early.

What does a successful first 30 days with Mae’s Grace look like?

Top priorities

Safety Companionship Hygiene Meals Mobility Transportation Family respite Dementia support Consistency

Are there problems the family hopes care will solve that have not been solved yet?

What would make the caregiver feel like a good fit?

Any prior provider experiences the family does not want repeated?

Authority, payment, and decision-making

Do not start care until authority, payment responsibility, and urgent contacts are clear.

Do not start until clear: Confirm who can approve services, sign the agreement, coordinate payment, and make urgent care decisions.

Who has authority to approve services and sign the care agreement? *

Who is responsible for payment or insurance coordination? *

Decision-maker involvement

Power of attorney Guardian Conservator Case manager Family decision-maker Client self-directs

Are all key family members aligned that care is needed?

Urgent contact 1 *

Urgent contact 2

Urgent contact 3

Authority / payment notes

Daily routine, independence, and personal care

Capture what the client can still do safely, where they need supervision, and where hands-on help is required.

Walk through a normal day from wake-up to bedtime

What does the client still do independently and safely?

Where are reminders, encouragement, or supervision needed?

Hands-on personal care needs

Bathing Grooming Dressing Toileting Incontinence care Oral care Linen changes Cueing only

Any embarrassment, resistance, or preferences around personal care?

Changes in hygiene, odor, skin, clothing cleanliness, or continence?

What helps the client feel respected and comfortable during personal care?

Mobility, transfers, and fall risk

Determine whether the care plan is safe for non-medical home care and whether additional support is needed.

How does the client move around the home?

Equipment used

Cane Walker Wheelchair Lift chair Shower chair Grab bars Hospital bed Gait belt

Transfer help required

Out of bed Standing from chair Toilet transfer Shower transfer Car transfer Not sure

Falls, near-falls, balance concerns, or emergency calls in the last 90 days?

Does the client try to move without help when it may not be safe?

Home safety and environment

Assess whether the home is safe for the client and safe for a caregiver to work.

Home hazards observed or reported

Stairs Loose rugs Clutter Poor lighting Narrow walkways Uneven flooring Bathroom hazards Other

Bathroom safety notes

Pets and visit instructions

Caregiver safety concerns

Smoking Weapons Unsafe visitors Aggressive behavior Pest concerns Sanitation issues No known concerns

How will the caregiver enter the home? *

What should caregiver do if no one answers?

Meals, hydration, household support, and medication boundaries

Clarify routine support while protecting the non-medical scope of care.

What does the client usually eat in a day?

Who shops and prepares meals now?

Food-related concerns

Appetite Weight loss Hydration Swallowing Diabetic diet Low sodium No known concerns

Household tasks requested

Light housekeeping Laundry Dishes Trash Linen changes Organizing Meal prep

Any household tasks the family does not want caregiver to do?

How are medications currently organized and managed?

Medication support requested Mae’s Grace should confirm non-medical boundaries if setup, administration, or medication management is requested.

Medical tasks requested or current clinical services involved

Memory, mood, behavior, and dignity

Understand what helps the client accept support and what may create avoidable conflict.

Memory, mood, and behavior concerns

Memory concerns Confusion Dementia Sundowning Wandering Anxiety Depression Agitation Refusal of care

When does behavior or confusion become worse?

What calms, motivates, or helps the client accept assistance?

Words, topics, routines, or approaches that upset the client

What should a caregiver know to preserve dignity and avoid conflict?

Personality, preferences, caregiver match, and schedule

Identify the caregiver style and schedule that will make the first week smoother.

Best caregiver personality fit

Quiet Talkative Structured Gentle Energetic Patient Humorous Task-focused

Preferred caregiver gender, language, culture, or communication style

Hobbies, faith, music, foods, shows, routines, or interests

What does the client still take pride in doing for themselves?

What should the caregiver never say, do, or assume?

Most important days and times for support

Highest-need times

Mornings Evenings Overnights Bathing days Appointment days Weekends

How soon is care hoped to begin?

Open to recommended hours if needed for safety and consistency?

Upcoming appointments, discharges, family events, or deadlines

Family communication, escalation, and safety boundaries

Set expectations for updates, urgent calls, refusals, major changes, and emergency response.

Who should receive updates after each shift?

Preferred update method

Text Phone call Email Portal Other

Details that matter most in shift updates

Mood Meals Hydration Toileting Hygiene Mobility Medication reminders Safety concerns Companionship

What counts as a major change that requires immediate contact?

Family members who should not receive updates or be involved?

When should Mae’s Grace call family immediately?

When should Mae’s Grace call 911?

What should happen if the client refuses care, food, bathing, entry, or asks caregiver to leave?

When should services pause until family, physician, home health, hospice, or emergency services are involved?

Internal observations, start readiness, and recommendation

Document what Mae’s Grace observed, what must be clarified before the first shift, and the recommended care plan.

Quietly observe: Does the stated care need match what you are seeing? Is the client’s voice respected? Is the family realistic about hours, cost, and safety?

Client observations

Home observations

Family observations

Do not start until clear checklist

Authority approved Primary contact confirmed Entry plan confirmed First-shift tasks clear Personal care clear Mobility/transfer needs clear Fall risks clear Safety concerns clear No out-of-scope medical tasks Escalation plan clear

Recommended care schedule

Recommended caregiver fit

Care plan summary and first-shift priorities

Start-of-care decision

Closing notes

Before submitting:

Confirm the family understands Mae’s Grace provides non-medical support, not skilled medical care. Confirm the first shift can be safe, organized, calm, and dignified.

I confirm this assessment is complete to the best of my knowledge and should be sent to Mae’s Grace leadership.

Assessment submitted. Mae’s Grace leadership will receive the assessment by email.

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