Questionnaire

1. Are you or your loved one interested in any of these services? (check all that apply)

• Grocery Shopping
• Bill Paying
• Monthly Budget
• Light Household Errands
• Resume/Document Writing
• Light House Keeping
• Light Home Maintenance
• Relocation Services
• Home Downsizing
• De-Cluttering Your Home
• Computer Training
• Personal Organization
• Waiting Around for Deliveries, Cable Guy, Repairman, Etc...

2. Are you or your loved ones in need of personal care? If so, please check all that apply.

• Help finding an assistant living residence
• Help finding a complete care residence
• In home full time care
• In home part time care
• Companion services

3. Are you or your loved one in need of local services?

• Help finding doctors/dentists in area
• Counseling services
• Elderly Check-In Service
• Community centers activity
• Long Distance Senior Monitoring
• Field trips
• Social activity

4. How soon are you looking to obtain the desired services?

• Within 30 Days
• 2 to 3 Months
• Within 6 Months
• Within a Year

Name

Contact Phone Number

Email Address