Elder Care Services Quiz
Complete this form to help us understand your elder care needs and connect you with the right services. All questions are designed to ensure the best possible support and comfort.
Who is this quiz being completed for?
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Myself
A family member
A friend or neighbor
Other
What is the current living situation?
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Living alone
With spouse or partner
With family
In assisted living
Other
Which daily activities require support?
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Meal preparation
Bathing or personal hygiene
Medication reminders
Housekeeping
Transportation
Companionship
Other
How would you describe mobility?
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Fully independent
Needs some assistance
Uses mobility aids (walker, cane, wheelchair)
Mostly homebound
Are there any cognitive or memory support needs?
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No support needed
Occasional reminders needed
Frequent reminders or supervision needed
Preferred care schedule
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Full-time (live-in)
Daytime only
Evenings or overnight
Occasional or as-needed
What type of social support is available?
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Nearby family
Friends or neighbors
Community services
Faith-based or volunteer support
No regular support
Preferred location for care
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In-home care
Adult day center
Community-based programs
Not sure / open to options
City or area where services are needed
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Contact name and best way to reach you
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First Name
Last Name
Your email address
*
example@example.com
Submit
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