Participant Name
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Medi-Cal ID
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Assessment Date
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Basic Needs
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Food, Clothing, and Essentials
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Food & Clothing / Essential Household Good Points
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Able to self-sustain basic needs?
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One Point
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1 to 2 times per year may not have means or access?
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Four Points
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Requires help at least 6 times per year?
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Six Points
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Consistently without most basic needs?
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Eight Points
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Justification: Food & Clothing / Essential Household Goods
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Activities of Daily Living
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Activities of Daily Living Points
/
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Requires no assistance?
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One Point
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Requires some assistance to perform 1 or more ADL?
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Four Points
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Requires complete assistance with ADLs?
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Six Points
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Requires complete assistance but receives none?
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Eight Points
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Justification: Activities of Daily Living
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Medical Needs
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Stable Health
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Stable Health
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Stable health with medical access?
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One Point
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Needs occasional assistance with treatment plan?
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Four Points
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Requires assistance with treatment or medications?
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Six Points
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Not accessing treatment or medication to control chronic conditions?
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Eight Points
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Unplanned hospitalizations/ED use in last year?
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Unplanned hospitalizations/ED use in last 6 months?
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Justification: Stable Health
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Living Situation
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Housing Stability
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Living Situation
/
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Has continued access to a stable community based living situation?
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One Point
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Occasionally needs short-term assistance with rent / utilities?
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Four Points
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Living in short-term, temporary housing?
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Six Points
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No available accessible housing to meet the needs of the participant?
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Eight Points
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Justification: Housing Stability
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Health & Safety of Housing
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Health & Safety of Housing
/
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Clean, habitable apartment or house?
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One Point
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Housing is habitable, but poses some access challenges to the participant?
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Four Points
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Housing is marginally habitable and could pose a direct effect on the health and/or safety?
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Six Points
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Housing is completely uninhabitable and participant’s health is directly affected?
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Eight Points
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Justification: Health & Safety of Housing
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Mental Health
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Mental Health
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No history of mental illness, psychological disorders, or psychotropic medications?
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One Point
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Has a diagnosed mental health disorder, but has regular and ongoing access to treatment?
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Four Points
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Un-stabilized mental health disorder because of non-compliance with medications, refusal or inability to participate in therapy?
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Six Points
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Danger to self or others without immediate intervention?
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Eight Points
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Justification: Mental Health
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Addictions
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Addictions
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No difficulties with addictions including: alcohol, drugs, sex, or gambling?
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One Point
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Past problems with addiction; less than one year in recovery?
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Four Points
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Current addiction but is willing to seek help in overcoming addiction?
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Six Points
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Current addiction; not willing to seek or resume treatment?
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Eight Points
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Justification: Addictions
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Activities of Daily Living
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Food & Clothing / Essential Household Good Points
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