(Previous/Current Perceived Needs) |
Which of the following programs are you currently using or have used. Please indicate the frequency of your use of a program (0: not used; 1: single use; 2: multiple uses but not weekly; 3: weekly; 4: twice a week; 5: more than twice a week) and your satisfaction with the program (0: not satisfied; 1: limited satisfaction; 2: some satisfaction; 3: moderately satisfied; 4: very satisfied; 5: extremely satisfied). If a program has not been used then a satisfaction score is not required. ____ ____Adult Protection Services ____ ____Chore Service Program/Homemaker services (Formal) ____ ____Caregiver Program (Alzheimer’s Association) ____ ____Grandparents Raising Grandchildren ____ ____Legal Assistance ____ ____Ombudsman (advocate for person in long-term care) ____ ____Options for Long-term Care (Who provided these options:_______________________) ____ ____Senior Nutrition Program ____ ____Senior Meal Site Locations ____ ____Community Partners ____ ____Adult Day Care ____ ____Consumer Affairs/Legal ____ ____Counseling/Mental Health & Support Groups ____ ____Durable Medical Equipment ____ ____Dental Care ____ ____Elder Abuse ____ ____Emergency Room/Urgent Care ____ ____Employment Services ____ ____Energy Assistance (Low Income Energy Assistance, LEAP; Weatherization) ____ ____Financial Assistance (County Dept. of Human Services, Social Security) ____ ____Food (Food Stamps, Grocery Delivery, Meals on Wheels, Nutrition Sites, Food Bank) ____ ____Health Education & Wellness (AAA, Community Wellness Line) ____ ____Health Insurance (Benefits Counseling, Health Insurance Counseling, Medicaid, Medicare) ____ ____Hearing & Vision Clinics ____ ____Home Health Care (Medical and Non-medical) ____ ____Hospice & Palliative Services ____ ____Hospital & Clinics ____ ____Housing (Subsidized) ____ ____Housing (Seniors Only Non-Subsidized, Low rent) ____ ____Housing (Assisted Living) ____ ____Information & Referral (AAA, Catholic Charities, Senior Resource Services, United Way) ____ ____Nursing Homes ____ ____Outpatient Physical & Occupational Therapy ____ ____Personal Alert Systems ____ ____Physician Care ____ ____Religious Programs ____ ____Respite Care (Day) ____ ____Senior Centers ____ ____Recreation Centers ____ ____Tax Preparation Assistance ____ ____Transportation (Medicaid medical transportation, Bus, Cabs, Friends, Family) ____ ____Veteran Services ____ ____Volunteer Opportunities (Where do you volunteer:___________________________) |