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The Wellbeing Program for Older Adults

Referral Form

Client Information

Day Month Year

Referrer Information

Family Contact

Reason for Referral

Describe the issue or problem that you believe needs to be addressed: (select as many options), and/or describe below:

Cornell Scale

Please think about how the client has been feeling over the last week. Please base your responses on what you've seen or heard yourself. For each item below, select the response that best represents your answer.

Observation Unable to score Absent Mild Severe
1. Anxiety (worrying frowning)
2. Sadness
3. Lack of reactivity to pleasant events
4. Irritability, easily annoyed, short tempered
5. Agitation (physical restlessness, hand wringing, hair pulling)
6. Slowness (slow movements, speech or reaction)
7. Multiple physical complaints
8. Loss of interest (in usual activities)
9. Appetite loss (eating less than usual)
10. Weight loss (lost weight in last month)
11. Lack of energy, fatigues easily
12. Diurnal variation of mood (e.g., symptoms worse in mornings)
13. Difficulty falling asleep (sleeps later than usual)
14. Multiple awakenings during sleep
15. Early morning awakening (earlier than usual)
16. Suicide (feels life is not worth living, suicide attempt or wishes)
17. Poor self-esteem (self blame, self depreciation, feelings of failure)
18. Pessimism
19. Mood congruent delusions (has ideas that other people consider strange - e.g., resident thinks that she/he is being punished)


Quality of Life (QOL)

Please think about different aspects of the resident's life - like physical health, energy, family, money and others. We want to find out your perceptions of the quality of the resident's life in each aspect. If you have difficulty rating any item, just give it your best guess. For each item below, select the response that best represents your answer.

Observation Unable to score Poor Fair Good Excellent
1. Physical health
2. Energy level
3. Mood
4. Living situation
5. Memory
6. Relationships with family members
7. Relationships with people who work here
8. Relationship with friends
9. How do they feel about themselves?
10. Ability to keep busy
11. Ability to do things for fun that they enjoy
12. Ability to take care of themselves
13. Life as a whole - everything together
14. Ability to make choices in life
15. Ability to live with others