Care Facility Selection Survey
Help us understand your priorities and preferences when choosing a care facility. Your feedback will guide us in identifying the most important factors in care facility selection.
Your Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Who is this care facility being considered for?
*
Myself
A family member
A friend
Other
What type of care is needed?
*
Assisted Living
Memory Care
Skilled Nursing
Rehabilitation
Respite Care
Independent Living
Other
How important are the following factors in your care facility selection?
*
Rows
Not Important
Somewhat Important
Very Important
Essential
Cleanliness
1
2
3
4
Staff qualifications
5
6
7
8
Safety and security
9
10
11
12
Quality of meals
13
14
15
16
Recreational activities
17
18
19
20
Facility location
21
22
23
24
Cost and affordability
25
26
27
28
Medical services availability
29
30
31
32
Please rate your overall impression of the facility you are considering.
*
1
2
3
4
5
Which of the following amenities are most important to you? (Select up to 3)
*
Private rooms
Outdoor spaces/gardens
On-site medical staff
Social activities
Physical therapy/gym
Transportation services
Other
How did you learn about this care facility?
*
Please Select
Referral from healthcare provider
Online search
Word of mouth
Advertisement
Other
What is your preferred location for the care facility? (City or Region)
Please share any additional comments or specific needs you have regarding care facility selection.
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