(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:___________________________)