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Client Acuity Scale Worksheet - Michigan

Client Name _____ Client Number _____ PAGE TOTAL _____ 1 Client Acuity Scale Worksheet Date of Assessment _____ Clients are assigned to a Level if they meet one or more of the criteria listed within each Level. Point values are different for different LIFE AREAS by page. Life Area Level #1 (1 point) Level #2 (4 points) Level #3 (6 points) Level #4 (8 points) Comments Basic Needs Level _____ Points _____ __ Food, clothing, and other sustenance items available through Client s own means.

Impairment Level _____ Points _____ __No signs of impairment. __Has ability to function independently. __Signs of impairment with no diagnosis; refer for evaluation. __Diagnosis of Developmental (DD) Disability/Cognitive Impairment with DD Services in place. __DD Diagnosis/Cognitive Impairment without DD Services.

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