The following form is based on a spreadsheet to be filled out. It is included in this packet for your reference.

Consumer Name:
LIFE/RUN Staff:
Date:
At Risk Factors
Y or N
1.  Does the Consumer feel that he or she is at risk of institutionalization?
2.  Has the Consumer been institutionalized in a long-term care facility (i.e., nursing home,       mental health facility, state school, prison/jail, etc.) within the last 12 months?"
3.  Is the Consumer Homeless?
4.  Has the Consumer been diagnosed with one or more of the following health conditions?
Coronary Heart Disease
Fractures due to falling
Decubitus (i.e., pressure sore/bed sore)"
Diabetes
Stroke
Cancer
Incontinence (bowel and/or bladder)
Mental Illness (i.e., Bipolar Disorder, Major Depression, Schizophrenia, etc.)"
Alzheimer's or other form of dementia
5.  Has the Consumer been hospitalized for any of the health conditions mentioned above in the last 12 months?
6.  Has the Consumer made 6 or more visits to the emergency room within the last 12 months?
7.  Does the Consumer need assistance with three or more activities of daily living (i.e., bathing, dressing, toileting, grooming, etc.) and does not currently have a care provider?"
8.  Is the Consumer 65 years of age or older?
9.  Does the Consumer have issues with taking medication(s) as prescribed?
10. Does the Consumer live alone? Note: If the Consumer is homeless, indicate ""No""."	
11.  Is the Consumer's current housing situation suitable (i.e., safe, accessible, rent and utilities current, etc.)?"
12.  Is the Consumer's income sufficient enough to cover basic living expenses such as, rent, utilities and food?"
13.  Does the Consumer have a history of drug and/or alcohol abuse?
14.  Does the Consumer have informal supports (i.e., help from spouse, children, siblings, friends, etc.)?"

Answers are tabulated in the spreadsheet to produce the “at risk score” and “at rist number.”