A social services assessment must contain, but is not limited to, the following:

Identifying information about the client (for example, name, address, age, gender, social security number, telephone number, certificate of Indian blood, education level), family history and medical history of the account holder;

Description of the household composition: information on each member of the household (e.g., name, age, and gender) and that person's relationship to the client;

The client's current resources and future income (e.g., VA benefits, retirement pensions, trust assets, employment income, judgment funds, general assistance benefits, unemployment benefits, social security income, supplemental security income and other governmental agency benefits);

A discussion of the circumstances which justify special services, including ability of the client to handle his or her financial affairs and to conduct day-to-day living activities. Factors to be considered should include, but are not limited to:

Age;

Developmental disability;

Chronic alcoholism or substance abuse;

Lack of family assistance or social support systems, or abandonment;

Self-neglect;

Financial exploitation or abuse;

Physical exploitation, neglect or abuse;

Senility; and

Dementia.

Documentation supporting the need for assistance (e.g., medical reports, police reports, court orders, letters from interested parties, prior assessments or evaluations, diagnosis by psychologist/psychiatrist); and

Summary of findings and proposed services to meet the identified needs of the client.