(agency)

Please share your views on the need for services for senior adults living in the community by completing this survey. Your responses may help determine future services for senior adults. Under each topic, place a “1” by the service you believe is most important to senior adults, a “2” by the second most important, and so forth.

1.    In-Home Services:
        ____Housework & personal assistance.
        ____Companion care.
        ____Adult Day Service (all day supervision and help in a community setting.)

2.    Health Care:
        ____Information on health issues & new medications.
        ____Helping seniors with health problems & alcohol/drugs/smoking cessation.
        ____Home health/nurses and nurses aide.
        ____Help in purchasing medications.

3.    Housing:
        ____Assisted living facilities.
        ____Home renovation.
        ____Independent community living.
        ____Public senior housing.

4.    Financial Problems:
        ____Assistance with writing checks, bill payments, & budgeting.
        ____Assistance completing Medicare & insurance forms.
        ____Assistance with applying for benefits and programs.

5.    Transportation:
        ____Transportation for medical appointments, shopping, visiting, etc.
        ____Transportation to medical specialist & treatment centers outside this area.
        ____Setting up a volunteer transportation network.

6.    Mental Health Service:
        ____Counseling in community centers.
        ____Support groups for issues such as grief and loss.
        ____In-home mental health counseling.
        ____Help & support for alcohol, medication misuse, & smoking cessation.

7.    Education & Recreation:
        ____Learning computer basics.
        ____Exercise, dancing, & walking classes or groups.
        ____Day trips to museums, wineries, historical sites, etc.
        ____Other classes or activities (suggestions):

Please rank the following services in order of their importance.
        ____Legal assistance, Wills, Powers of Attorney, & mediation services.
        ____Elder Abuse, Neglect, & Financial Exploitation services.
        ____Crime issues, scams, fraud, personal safety, & safety education.
        ____Information on re-entry into the workforce.
        ____Home delivered meals.
        ____Congregate meals at a community center.
        ____Information & assistance and outreach visits to the homes of senior adults.
        ____Help with problems in nursing homes, residents rights & resident councils.

Do you have any comments about services or gaps in services for seniors? We are also interested in any comments you have on caregiving issues or problems that families and seniors face.

Do you or your agency need information on the changes to the Circuit Breaker & Pharmaceutical Assistance Program? ____ Yes ____ No

Agency/person responding to this survey:____________________________________.

THANK YOU!