Area Agency on Aging哈里斯郡老人事務總署of HARRIS COUNTY

HARRIS COUNTY ACCESS PROJECT 哈里斯郡失智老人關懷網

# CAREGIVER INTAKE看護者資料表

**All information provided will be kept confidential and guarded against
unofficial use. Information gathered through an intake or through an
assessment may be shared to effectively plan, arrange and deliver
services to meet individual client needs.**

**這份資料是德州老人及殘障服務部及老人事務總署的服務部門要求的.
所有的資料保密, 並不對外使用.
所有資訊將根據這表格上個人的需要提供不同的服務.**

**[Release of information has been clearly explained to the
client.]{.underline}**

**已向當事人解釋清楚要提供以下的資料**

**Date日期***:* \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ **Client ID
Number註冊號碼** : \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Last Name姓:** \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**MI**: \_\_\_\_\_\_\_\_\_\_ **First Name名:**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Street Address/Apt.
#地址**:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**City城市**: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**State州**:
\_\_\_\_\_\_\_**Zip Code郵遞區號**: \_\_\_\_\_\_\_\_\_\_\_\_
**County郡**: \_\_\_\_\_\_\_\_\_\_\_\_\_

**Phone電話**: (\_\_\_\_\_) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**Gender性別**: **Male男** **Female女** **Birth
Date出生日**:\_\_\_\_\_\_\_\_\_

![](media/image1.png){width="7.625in" height="0.10416666666666667in"}

+------------------+---+-------------------------+---+-----------+----+
| *                |   | **Race 種族(Check all   |   | Marital   |    |
| *Ethnicity族裔** |   | that apply):**          |   | Status    |    |
|                  |   |                         |   | (Check    |    |
| **(Check         |   |                         |   | One):     |    |
| One請選一項):**  |   |                         |   |           |    |
|                  |   |                         |   | *         |    |
|                  |   |                         |   | *婚姻狀況 |    |
|                  |   |                         |   | (         |    |
|                  |   |                         |   | 請選一)** |    |
+------------------+---+-------------------------+---+-----------+----+
| (1) **Hispanic   |   | **(1) White -- Non      |   | \(1\)     |    |
|     or Latino    |   | Hispanic 非西裔白人**   |   | Married   |    |
|     西裔**       |   |                         |   | 結婚      |    |
|                  |   | **(2) White -- Hispanic |   |           |    |
| (2) **Not        |   | 西裔白人**              |   | \(2\)     |    |
|     Hispanic or  |   |                         |   | Widowed   |    |
|                  |   | **(3) American          |   | 鰥寡      |    |
|   Latino非西裔** |   | Indian/Alaska Native**  |   |           |    |
|                  |   |                         |   | \(3\)     |    |
| > **(3)          |   | **美裔印地安/           |   | Divorced  |    |
| > Ethnicity Not  |   | 阿拉斯加原住民**        |   | 離婚      |    |
| > Reported**     |   |                         |   |           |    |
| >                |   | **(4) Asian 亞洲人**    |   | \(4\)     |    |
| >                |   |                         |   | Separated |    |
| **族裔未經告知** |   | **(5) Black or African  |   | 分居      |    |
|                  |   | American**              |   |           |    |
|                  |   |                         |   | \(5\)     |    |
|                  |   | **黑人或非裔美人**      |   | Never     |    |
|                  |   |                         |   | Married   |    |
|                  |   | **(6) Native Hawaiian   |   |           |    |
|                  |   | or Pacific Islander**   |   | 從        |    |
|                  |   |                         |   | 未結過婚  |    |
|                  |   | **夏威夷原              |   |           |    |
|                  |   | 住民或太平洋島嶼居民**  |   | \(6\) Not |    |
|                  |   |                         |   | Reported  |    |
|                  |   | **(7) Persons Reporting |   |           |    |
|                  |   | Some Other Race**       |   | 未經告知  |    |
|                  |   |                         |   |           |    |
|                  |   | *                       |   |           |    |
|                  |   | *當事人告知是其他種族** |   |           |    |
|                  |   |                         |   |           |    |
|                  |   | **(8) Race Not Reported |   |           |    |
|                  |   | 種族未經告知**          |   |           |    |
+------------------+---+-------------------------+---+-----------+----+

![](media/image1.png){width="7.61875in" height="0.10416666666666667in"}

**[Relationship to Care Recipient(s)]{.underline}**

**[與被看護者之間的關係]{.underline}**

**Husband 先生** **Wife太太** **Son/Son-in-Law兒子/女婿**
**Daughter/Daughter-in-Law女兒/媳婦**

**Other Relative親戚關係** **Non-Relative 沒有親戚關係** **Relationship
Missing 關係未經告知**

**[Was the person diagnosed with Alzheimer's Disease or related
dementia?]{.underline}** **Yes** **No**

當事人是否患有老人失智症或相關的失智症狀? 有 沒有

**When was the diagnosis made?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

何時診斷出患有此病?

**Who diagnosed the person** **Family Physician** **Specialist**
**Diagnositc Center**

是誰診斷出此疾病 家庭醫生 專科醫生 診斷中心

**Are there any other health problems that the person is currently being
treated for?** **Yes** **No**

目前病患是否同時在治療其他的疾病? 有 沒有

**If yes please describe**
如果有其他疾病,請詳細說明是什麼疾病\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**[Relationship to Care Recipient (s)
你與被看護者是什麼關係]{.underline}**

**Grandparents****祖父母** **Other Elderly Relative長輩親戚關係**
**Other Elderly Non-Relative非親戚長輩**

-   Does the Caregiver live with the Care
    recipient看護者與被看護者同住嗎? Yes 是 No不是

-   If no, how often does the Caregiver have contact with the Care
    Recipient?
    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> 如果沒有同住, 看護者多久才與被看護者連絡?
> ![](media/image1.png){width="6.75in" height="0.10416666666666667in"}

**CARE RECIPIENT PROFILE 被看護者資料**

Language spoken at home: \_\_\_\_\_\_\_\_\_\_\_\_\_\_ Does the Care
Recipient require an interpreter? Yes是 No 不用

在家中說的語言 被看護者須要翻譯嗎 ?

If yes, who helps in the interpretation如果須要翻譯, 誰來幫忙翻譯?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

-   [If care recipient is 60 years of age or older complete the
    following 如果被看護者超過60歲請填寫以下資料:]{.underline}

Date日期*:* \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**Client ID Number號碼:**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Last Name姓: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ MI:
*\_\_\_\_\_\_\_* First
Name名*:*\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Street Address/Apt. #地址*:*
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

City城市:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_State州*:*\_\_\_\_\_\_
Zip Code郵遞區號: \_\_\_\_\_\_\_\_\_\_\_
County郡:\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Phone電話: (\_\_\_\_) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Gender性別:
Male男 Female女 **Birth Date出生日**: \_\_\_\_\_\_\_\_\_\_\_

![](media/image1.png){width="7.5in" height="0.10416666666666667in"}

+------------------+---+--------------------------+---+-------------+---+
| Ethni            |   | Race**種族(** Check all  |   | Marital     |   |
| city**種族淵源** |   | that apply請選所有可能): |   | Status      |   |
|                  |   |                          |   | (Check      |   |
| (Check           |   |                          |   | One):       |   |
| O                |   |                          |   |             |   |
| ne**請選一項**): |   |                          |   | **婚姻狀況  |   |
|                  |   |                          |   | (請選一)**  |   |
+------------------+---+--------------------------+---+-------------+---+
| (1) Hispanic or  |   | \(1\) White Non          |   | \(1\)       |   |
|     Latino 西裔  |   | Hispanic,非西裔白人      |   | Married     |   |
|                  |   |                          |   | 結婚        |   |
| (2) Not Hispanic |   | \(2\) White -- Hispanic  |   |             |   |
|     or Latino    |   | 西裔白人                 |   | \(2\)       |   |
|                  |   |                          |   | Widowed     |   |
| > 非西裔         |   | \(3\) American           |   | 鰥寡        |   |
|                  |   | Indian/Alaska Native     |   |             |   |
| (3) Ethnicity    |   |                          |   | \(3\)       |   |
|     Not Reported |   | **美裔印地安/            |   | Divorced    |   |
|                  |   | 阿拉斯加原住民**         |   | 離婚        |   |
| > 族裔未經告知   |   |                          |   |             |   |
|                  |   | \(4\) Asian 亞洲人       |   | \(4\)       |   |
|                  |   |                          |   | Separated   |   |
|                  |   | > \(5\) Black or African |   | 分居        |   |
|                  |   | > American               |   |             |   |
|                  |   | >                        |   | \(5\) Never |   |
|                  |   | > **黑人或非裔美人**     |   | Married     |   |
|                  |   |                          |   |             |   |
|                  |   | \(6\) Native             |   | 從未結過婚  |   |
|                  |   | Hawaiian/Other Pacific   |   |             |   |
|                  |   | Islander                 |   | \(6\) Not   |   |
|                  |   |                          |   | Reported    |   |
|                  |   | **夏威夷                 |   |             |   |
|                  |   | 原住民或太平洋島嶼居民** |   | 未經告知    |   |
|                  |   |                          |   |             |   |
|                  |   | \(7\) Persons Reporting  |   |             |   |
|                  |   | Some Other Race          |   |             |   |
|                  |   |                          |   |             |   |
|                  |   | **當事人告知是其他種族** |   |             |   |
|                  |   |                          |   |             |   |
|                  |   | \(8\) Race Not Reported  |   |             |   |
|                  |   | **種族未經告知**         |   |             |   |
+------------------+---+--------------------------+---+-------------+---+

![](media/image1.png){width="7.625in" height="0.10416666666666667in"}

Monthly Household Income每月家庭收入:\$\_\_\_\_\_\_\_\_\_\_ Low
Income低收入 Moderate Income中等收入 High Income高收入

{Low Income Levels for低收入標準: Single person family unit
一人家庭收入低於 \$ 9,800; {Two person family unit二人家庭收入低於 --
\$13,200}

**[If caregiver is a 60+ grandparent or relative of a child 18 years of
age or younger who:]{.underline}**

**[若看護者是60歲以上的祖父母或親戚在扶養18歲以下的幼童:]{.underline}**

-   **[lives with the child 與幼童同住,]{.underline}**

-   **[is the primary caregiver of the child because the biological or
    adoptive parents are unable or unwilling to serve a the primary
    caregiver of the child, and]{.underline}**

> **[是幼童的主要看護人, 因為生理或領養的父母不能或不願意照顧幼童
> ,並且]{.underline}**

-   **[has a legal relationship to the child, such as legal custody or
    guardianship, or is raising the child
    informally是與幼童有合法的關係人身份, 例如法律上的保護人或監護人,
    或是非正式的扶養幼童;]{.underline}**

**[complete the following請填寫以下部份:]{.underline}**

Number of Children 18 years of age or younger for whom the individual is
providing care: **\_\_\_\_\_\_\_**

**有幾位18歲及以下的幼童是被當事人個人照顧扶養長大的.**

List identification number(s), name(s), birth date(s), gender(s) and
relationship(s) of children 18 years of age or younger:

請登記註冊號碼, 姓名, 出生日期, 性別, 及與18歲以下幼童之間的關係.

+-------------+------------+--------+-----+--------------------------+
| **Client ID | **Name**   | *      | *   | **Relationship**         |
| Number**    |            | *Birth | *Ge |                          |
|             | **姓名**   | Date** | nde | **與                     |
| **註 冊 號  |            |        | r** | 18歲以下幼童之間的關係** |
| 碼**        |            | **出生 |     |                          |
|             |            | 日期** | *   |                          |
|             |            |        | *性 |                          |
|             |            |        | 別  |                          |
|             |            |        | **  |                          |
+-------------+------------+--------+-----+--------------------------+
|             | 1\.        |        |     |                          |
+-------------+------------+--------+-----+--------------------------+
|             | 2\.        |        |     |                          |
+-------------+------------+--------+-----+--------------------------+
|             | 3\.        |        |     |                          |
+-------------+------------+--------+-----+--------------------------+
|             | 4\.        |        |     |                          |
+-------------+------------+--------+-----+--------------------------+
|             | 5\.        |        |     |                          |
+-------------+------------+--------+-----+--------------------------+

Comments意見:
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**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Signature of AAA/Provider Staff Completing Intake** **Date** 日期