CHC Pre-Eligibility Assessment

Care Receiver's First Name

Care Reciever's Last Name

Care Reciever's Date of Birth

The following 12 'domains' are assessed to determine eligibility:

1. Behaviour 7. Continence

2 Cognition 8. Skin Integrity

3. Psychological and 9. Breathing

Emotional Needs 10. Drug Therapy/Medication

4. Communication 11. Altered States of Consciousness

5. Mobility 12. Other

6. Nutrition

Please note, the care receiver does not have to be receiving care within all the domains. Eligibility depends on overall care needs so give as much detail where possible.

Please give details in relation to the 12 domains

Contact Number

Place of Care

Please fill in the details below if you are acting on behalf of the care receiver:

First name

Last name

Relationship