Adult Services Annual Assessment
I. Social (Complete or modify face sheet as needed.)
A. Client's/family's perception of client's social functioning.
B. Changes in the client's/family's social functioning since the last assessment or reassessment (e.g.,
changes in the household composition, changes in the dynamics and quality of client's or family's
relationships, losses or changes in social support.) Update the Face Sheet as necessary.
C. Has there been a change in the client's preferred emergency contact person?
If yes, update the Face Sheet.
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A. Client's/family's perceptions of the home and neighborhood environment.
B. Type of residence
Other - Explain below
Specify shelter below
D. If client lives in a house, mobile home, or apartment, who is head of household?
List below head of household or if Other - Explain
E. Inadequate, unsafe, or unhealthy conditions in client's environment (space for comments/
explanations below if needed.) If client is in a facility, record environmental issues/concerns under
Yard or other area
side of residence
List Comments/Explanations and/or Describe Other below.
F. Is there anything in the home or neighborhood that poses a threat to the client's mental or physical
health, safety, or ability to receive services?
G. What impact have changes in the environment in the past year had on the lives of the client/
family (May include positive and negative impact.)
III. Mental/Emotional Ass