Home Visit Needed Request Activities Of Daily Living - Client Information Form
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1CAS-102 (E) 03/01/2011
Home Visit Needed Request
Activities of Daily Living – Client Information Form
To assist the New York City Human Resources Administration (HRA) in determining your ability to travel and attend required
appointments , please complete and sign this form and provide copies of any medical records that would help in making this
determination.
Name: _____________________________Case Number (if applicable):
________________
SSN:
_____________
Date of Birth:
_____________________
Gender:
_______
Phone:
________________________
Address:
____________________________________________________________________________________
Do you have any medical conditions?
Yes
No If yes, list:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Do you have any mental health conditions?
Yes
No If yes, list:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Are you taking any medication?
Yes
No If yes, list:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Do you have a doctor?
Yes
No If yes:
Doctor’s Name: ________________________________________________Phone:
_______________________
Address:
___________________________________________________________________________________
How do you get to your doctors’ appointments?
____________________________________________________________________________________________
Are you able to travel to a medical assessment at WeCARE?
Yes
No
Do any of your medical and/or mental health conditions make it hard for you to:
1. Travel to appointments
Yes
No
2. Take public transportation?
Yes
No
3. Travel outside of the home without a companion?
Yes
No
4. Attend medical or other appointments?
Yes
No
5. Go food shopping or handle other routine errands?
Yes
No
If yes to any of the above, explain:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Do you have a home attendant or other home care services?
Yes
No Daily hours of home care
_______
Do you have someone who can escort you to appointments or run errands for you?
Yes
No
Do you have an application pending with the Social Security Administration for federal disability benefits (SSI
or SSDI)?
Yes
No
I certify that the statements above are accurate and true to the best of my knowledge.
Signature:
_______________________________________________________
Date:
_____________ _____
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