*1.Do you understand the definition of senior-adult daycare?(Required.)

YES

NO

*2.Would someone in your circle of family or friends use the services of a senior-adult daycare center?(Required.)

YES

NO

3.If so, how many days per week?

1

2

3

4

5

4.Half days or full days?

HALF

FULL

*5.What do you think is a fair price for a half day of services?(Required.)

$10

$20

$30

$40

$50

*6.If the costs were not covered by insurance or other programs, would you be willing to pay out of pocket?(Required.)

YES

NO

*7.What types of services would yo like to see for your loved one at a senior-adult day care center? Check the boxes below.(Required.)

Social interaction

Medication management

Memory exercises

Bathing

Transportation to appointments

Crafts and games

Meals and snacks

Guest speakers

Occupational Therapy

Physical Therapy

8.Optional:  Contact information

Name

Address

City/Town

State/Province

ZIP/Postal Code

Phone Number

9.Leave any other comments here below.