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HEALTH OF MIND PRELIMINARY ASSESMENT

Identifying individual needs is one of the hardest parts when coordinating home and community-based service and effective care of basic needs is critical in customer satisfaction and wellbeing. However, not all caregivers approach these services the same (i.e., Supported Employment, Supported Living Coaching, In-Home Support, Companion, Respite, and Personal Care Assistance). The Health of Mind Preliminary Assessment or HMPA is not a test (i.e., no metric properties) so there are no right or wrong answers. This instrument was designed to help individuals, waiver support coordinators, and caregivers identify obstacles in different areas of functioning or clusters: health, financial, leisure activities, and meal and nutrition. It presents 36 statements and asks you to decide whether they are or are not current needs. By identifying which area you need to work on most, the HMPA can help you make solid choices and take control of your life. Please read each statement carefully and mark the statements that best describe your needs. Use the “others:” and “Notes” space for the needs not identified.

ABOUT THE INDIVIDUAL:
Date:
Name:
Date of Birth:
Gender:
Phone Number:
Home Address:
Email:
ABOUT THE RESPONDENT:                 CLICK HERE TO DISPLAY FORM
Relationship to Individual:
Name:
Date of Birth:
Gender:
Phone Number:
Home Address:
Email:
HEALTH:
FINANCIAL:
Make or cancel medical/dental appointments.
Mail/ delivery bills
Adhere to medication regimen.
Purchase items from a shopping list.
Order prescriptions from physicians or refill medications
Use bank for basic transactions.
Make exercises (e.g. walks, jogs, aerobics,
swims, karate, weight lifting, etc)
Reconciles check register with monthly statement.
Comply with specific doctor’s recommendations
Develop a budget system
Others
Others
SUPPORT COUNSELING:
MEAL AND NUTRITION:
 Talk about personal problems
Prepare simple food (e.g., cereal, sandwiches, salad, etc)
Explore alternatives to resolve personal problems.
Clean up following meals
Utilize relaxation techniques to cope with life stressors
Improve healthy eating habits
Take steps to reduce external sources of stress
Follow an specific diet
Others
Others
COMMUNITY RESOURCES:
COMMUNITY ACCESS:
Assist to obtain or maintain benefits (e.g., SSI, Food Stamps, etc)
Access to the community (e.g., shopping, libraries, etc)
Assist within the community with personal matters (e.g., school)
Participate in extracurricular activities, outings, and community events
Register to vote or vote
Visit family and friends
Coordinate Special Transportation Service (STS)
Navigate to desired destinations, including dr.’s appointments
Others
Others
HOUSEHOLD MANAGEMENT:
LEISURE ACTIVITIES:
Care of floors, carpeting, walls, windows, and bathrooms
Assist to uses audiovisual equipment (e.g. TV, VCR, CD, radio, computer, etc)
Take trash to curb on garbage day
Reads books, magazine, newspapers, etc and talk about them
Clean equipments (e.g., microwaves, coffee maker, oven, refrigerator, etc)
Attends cultural events (e.g. plays, lectures, exhibits, concerts, festivals, etc)
Make beds and change linens
Do gardening
Organize drawers and closets
Do arts and crafts
Others
Others
NOTES:
 

Please choose the days you need the service!
Monday
Morning
Afternoon
Evening
Tuesday
Morning
Afternoon
Evening
Wednesday
Morning
Afternoon
Evening
Thursday
Morning
Afternoon
Evening
Friday
Morning
Afternoon
Evening
Saturday
Morning
Afternoon
Evening
Sunday
Morning
Afternoon
Evening



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