Form Ag-095 - Arizona Standardized Client Assessment Plan (Ascap)
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15AG-095 (11-14)
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Division of Aging and Adult Services
RESET
ARIZONA STANDARDIZED CLIENT ASSESSMENT PLAN (ASCAP)
ASSESSMENT DATE
DAARS ID NO.
NEW
REASSESSMENT
CHANGE
REVIEW
CLOSE
HOLD
PART I: INTAKE INFORMATION
A. Client Profile and Referral Information
FIRST NAME
LAST NAME
M.I.
SOC. SEC. NO.
DATE OF BIRTH
PHONE NO. 1
PHONE NO. 2
HOME
WORK
CELL
HOME
WORK
CELL
FAX
CAR
OTHER
FAX
CAR
OTHER
HOME OR RESIDENCE ADDRESS (No., Street, Apt. No., City, State, ZIP)
MAILING ADDRESS (P.O. Box, Street, City, State, ZIP)
VALID DATES
VALID DATES
From
To
From
To
E-MAIL ADDRESS 1
PERSONAL
WORK
OTHER
E-MAIL ADDRESS 2
PERSONAL
WORK
OTHER
Yes
No Needs emergency evacuation assistance
Yes
No Is a primary caregiver (informal) assisting you?
(based on responses in Part IV).
INFORMATION FOR INTERVIEW WAS OBTAINED FROM
Self report
Medical records
Other (specify)
NAME OF REFERRAL SOURCE
REFERRAL SOURCE PHONE NO.
REFERRAL DATE
REFERRAL SOURCE ADDRESS (No., Street, Apt. No., City, State, ZIP)
REFERRAL SOURCE TYPE
Self
Hospital
Senior center
Family
Agency
AHCCCS health plan
Friend
Residential facility
AHCCCS – ALTCS
Physician
APS
Other
LOCATION AT TIME OF REFERRAL
ADMISSION DATE
DISCHARGE DATE
Hospital
Emergency room
Community
LTC facility
ELIGIBILITY CATEGORY
ELIGIBLE CLIENT (associated with spouse or caregiver)
NAME
60 and over
Spouse of client age 60 and over
SOC. SEC. NO.
Under 60 with a disability
Caregiver of eligible client
B. Demographics
TYPE OF DISABILITY
ETHNICITY
Physical
Traumatic brain injury
Hispanic or Latino
Intellectual disability/developmental
Dementia
Not Hispanic or Latino
disability (ID/DD)
Other (specify)
Declined to state
Mental illness
None
RACE
RELATIONSHIP STATUS
LANGUAGE
Asian
Divorced
English
Black/African American
Domestic partner
American Indian (w/Eng)
Native Hawaiian or other Pacific Islander
Married
American Indian (w/o Eng) (specify):___________
American Indian or Alaskan Native
Separated
Spanish (w/Eng)
White
Single
Spanish (w/o Eng)
Other
Widowed
Other (specify):
Declined to state
Declined to state
Declined to state
ENGLISH FLUENCY
EDUCATION
Fluent
Grade school or less
Limited
Some high school
Needs translation
High school graduate
Declined to state
Post high school
College degree
Declined to state
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