1Say what you want to do yourself.
2Choose one thing you need help with.
3Agree who can help and when.
4Say if the arrangement is inconvenient.
Start with an ordinary day
Walk through the day in your parent’s words: getting things ready, meals, household jobs, going out, and contact with others. Ask which task would be easier with help. Do not turn a preference for assistance into a judgment about ability. If a physical difficulty needs assessment, bring that question to a doctor.
Describe help as an actual task
Write a task with a clear beginning and end, such as collecting a grocery order and putting it in the agreed place. Ask about timing and preferences. Avoid entries such as “take care of everything.” An agreed delivery does not include cleaning the kitchen unless the helper has accepted that task too.
Leave space for changes
Keep today’s plan short. Confirm whether a meal, outing, or appointment has changed before arranging help around it. Record “not needed today” separately from “no helper available.” For medication reminders, use only the current doctor-confirmed instructions and the separate medication record; do not invent a schedule here.
Check whether the arrangement works
Ask whether the timing and way of helping suited your parent. If something was missed, record the gap without blame and ask who can realistically help next. Do not use this sheet as a clinical activities-of-daily-living assessment. It cannot decide care eligibility, a diagnosis, or the amount of professional support someone needs.
Use the worksheet for one real situation
Open the matching sheet below. Review the preparation checklist, then write the information your family needs in the labeled fields. Leave unknown details blank and record who can clarify them.
My choice
What I want to keep doing
Help wanted
One specific household task
Agreement
Person and time confirmed
Review
Did it work for me?
Print a blank copy to write by hand, or fill it in on this page before printing. Give the completed copy only to people your parent has agreed may see it. The checklist records preparation; it does not score safety or verify a medical decision.
Common questions
Is this an ability score?
No. It records choices and household help, without assigning a health or independence score.
Must every box be filled?
No. Use only the tasks relevant that day. A shorter useful list is enough.
What if the help needed changes?
Discuss practical arrangements with the family or service. Ask a doctor about medical concerns or assessment needs.
Source and scope
Background on sharing family responsibilities. The contact agreement and handover examples here are original templates, not a monitoring service.
The examples and worksheets are original household planning tools. For symptoms, medication decisions, or other medical questions, contact a doctor.