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Arizona Programs and Services

AZ Links Partners and Projects

When you have completed the form, click the ‘Submit’ button at the bottom of the page, an Information Specialist from your local Area Agency on Aging will contact you to discuss the options that are available to you.

Please submit a separate Screening Tool for each person seeking services.

1. *What is your primary reason for filling out this Screening Tool?

2. *Have you contacted your local AAA before?

No

Yes

3. *I am seeking information/care for:

4. *Please select a County / Location:

5. *The date of birth of the person identified above is (month-day- year):

Month:

Day:

Year (four-digit format 1944):

6. Assistance with the following tasks is needed: (check all that apply)

Bathing

Eating

Communicating

Dressing/Grooming

Medication reminders or supervision

Mobility

Toileting

Transferring (from bed into wheelchair)

None

Other

7. Assistance with the following household chores is needed: (check all that apply)

Cooking

Housekeeping

Money Management

Shopping

Telephone Calls

Transportation

None

Other

8 .The current care situation is such that: (check all that apply)

Periods of more than 24 hours when left alone

Care needs are often unmet

Inadequate opportunities to socialize with others

Family and friends do not live close enough to visit on a regular basis

Periods of memory loss

Episodes of grief and loss

Frequent or occasional falling

Thoughts of depression

Thoughts of suicide

Generally sufficient care for my needs

9. Most pressing needs are: (check all that apply)

Assistance with Housekeeping

Assistance with Personal Care

Assistance with reconciling medical bills and insurance records

Behavior assistance

Benefits counseling (public benefits)

Care in case of emergency

Care management

Companionship

Educational assistance

Employment

End of Life Care/Hospice

Food

Grandparent services

Housing

In-home instructions for daily living

Legal advice or estate planning

Mental health support

Medication and appointment reminders

Medication management

Nutrition counseling

Occupational Therapy

Ombudsman (advocacy rights)

Physical Therapy

Prescription drug assistance

Rehabilitation (from surgery/accident/stroke/etc.)

Respite (temporary relief for a Caregiver)

Skilled nursing care

Social/Recreational/Welllness Reminders

Speech Therapy

Support services for Caregivers

Utility assistance

10. Monthly (GROSS) income level is:

For an individual, No more than:

For a couple, No more than:

11. Current health insurance coverage is: (check all that apply)

AHCCCS/ALTCS (Medicaid)

Indian Health Services

Long-Term Care Insurance

Medicare

Supplemental Insurance

Veteran’s Administration

None

Other

12. Medical conditions include: (check all that apply)

Alcohol/Substance Abuse

Alzheimer's or Dementia

Arthritis

Autism

Brain injury

Cancer

Cerebral Palsy

Cognitive Disability

Developmental Delay

Diabetes

Epilepsy

Hearing impairment

Heart problems

HIV/AIDS

Multiple Sclerosis

Paralysis

Parkinson’s Disease

Pulmonary (lung) disease

Recovering from surgery, infection, or injury

Spinal cord injury

Stroke

None

Other

13. * I was referred by:

Your contact information:

*Your first name:

Your area code and phone number:*

*Zip:

Alternate phone number:

Email Address:*

 

(You will be prompted to complete any required fields that are blank.)