Form 2059, 2009, Summary Of Client'S Need For Service
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1Texas Department of Aging
(Auto) Form 2059
Summary of Client’s Need for Service
and Disability Services
September 2009
Client No.:
Client Name:
Action Type:
Assessment Date:
1. Conditions which cause functional limitations:
2. Why is client unable to perform, or is limited in, activities of daily living?
3. Description of client’s home environment:
Residence
Adequate
In town/suburb
Home equipped with electricity, heat, water, and plumbing
Rural area, easily accessible
Rural area, difficult to access
Miscellaneous
Isolated
Special-equipped vehicle for transport
No residence
Other:
Assistive Devices
Other – Comments:
Ramp
Laundry
Hospital Bed
Washer and Dryer
Grab bars
Washer only
Portable toilet
Neither
Other:
Explanation of specific problems that impact service delivery:
Unsafe
Questionable
Unsanitary
No water
No telephone
Severe state of disrepair
No plumbing/needs major repairs
Extreme clutter
Other:
No electricity
Dangerous pets
No A/C or fan
Other:
4. Client’s Living Arrangement:
5. Explanation of current and ongoing role of family or caregiver in meeting client’s needs:
Support Name
Primary Support Type
Reason Why Need of Client Cannot Be Met
6. Common Household Task(s) being purchased and the reason:
7. What other services is client currently receiving or being referred for?
8. Agency(ies) Selected:
Service:
Provider ID:
Provider DBA Name:
Method of Selection:
Printed:
User:
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