DO NOT sign your name, but please tell us a little about you.
Please circle the response that best describes you.
1. What is your age?
2. Are you …
Please circle the number at the right
that best describes your needs.
|
Very Important to me |
Somewhat Important to me |
Not Important to me |
MEALS AND NUTRITIONAL NEEDS ...
|
| Socializing at the senior center |
3 |
2 |
1 |
| Meals at the senior center |
3 |
2 |
1 |
| Availability of home delivered meals |
3 |
2 |
1 |
| Having enough food in the house |
3 |
2 |
1 |
| Food pantries to help stretch my food budget |
3 |
2 |
1 |
| Food stamps (Illinois LINK Card) |
3 |
2 |
1 |
TRANSPORTATION ISSUES ...
|
| Transportation to senior center, doctor, shopping, etc. |
3 |
2 |
1 |
| Transportation for out-of-the-area medical treatment |
3 |
2 |
1 |
MENTAL HEALTH SERVICES ...
|
| Help with issues such as grief and loss |
3 |
2 |
1 |
| Someone to talk to about problems and worries |
3 |
2 |
1 |
| Finding a support group |
3 |
2 |
1 |
| Having a counselor come to my home |
3 |
2 |
1 |
| Speaking with a counselor in the senior center |
3 |
2 |
1 |
EDUCATION & RECREATION ISSUES ...
|
| Exercise, dancing, & walking groups and classes |
3 |
2 |
1 |
| Day trips for entertainment, site seeing, etc. |
3 |
2 |
1 |
| Learning more about computers |
3 |
2 |
1 |
OTHER ISSUES ...
|
| Help taking care of a spouse or loved one |
3 |
2 |
1 |
| Obtaining an emergency response system |
3 |
2 |
1 |
| Help with dental care |
3 |
2 |
1 |
| Help paying for medications |
3 |
2 |
1 |
| Help fixing up my house |
3 |
2 |
1 |
| Help writing checks to pay bills |
3 |
2 |
1 |