Name of the LTC@Home Participant? *

First Name

Last Name

Participant Phone Number *

(###)

###

####

Support Person or Emergency Contact

In order to participate in the virtual assessment, we ask that you have a trusted family member or friend present to help.

First Name

Last Name

Virtual Home Safety Assessment

In order to ensure a virtual assessment is appropriate, please confirm the following:

A support person is available to assist during the assessment

Medical conditions are stable

We can tour your home using your LTC@Home iPad

Consent for Assessment

During the assessment you will be asked a number of questions related to your particular circumstance, concern/difficulties, and personal goals. You may also be asked to demonstrate various tasks.

I agree to participate

Privacy & Sharing of Information

I authorize Anew Rehab and its associated health professionals to collect my personal and medical information as documented above. I understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission.

I agree

Disclosure of Information

As a participant in the LTC@Home program, you have the option to share a copy of your assessment summary and recommendations with the program. Providing this information is voluntary and not required to receive services. However, sharing it would be helpful for program evaluation and may support efforts to demonstrate outcomes and secure future funding or program extensions.

I agree

Assessment Availability *

Please indicate your availability for a 45-minute virtual assessment. Appointments are offered Monday to Friday, between 9:00 a.m. and 4:00 p.m.

Monday

Tuesday

Wedensday

Thursday

Friday

AM (9:00 - 12:00)

PM (12:00 - 4:00)