Site User 10-Question Survey PLEASE NOTE: This survey is being used for data collection. CareSpotlight will not be following up with you individually regarding your answers. Please know that you are helping us to decipher what type of assistance people are seeking. If you include your email address, we will let you know when the website officially launches and at that time you will be able to connect to others, access information, etc. THANK YOU! Question Title * 1. Are you currently a caregiver and/or advocate to a family member or friend who is aging; has a physical, developmental and/or intellectual disability; has been diagnosed with a serious mental illness; is chronically or terminally ill; or has been seriously injured? Yes No Question Title * 2. If you answered "yes" to question #1, is that person your: Self Child Parent Spouse or Partner Sibling Relative Friend Other (please specify) Question Title * 3. Please check all that apply: I am seeking care and/or services for myself. I am seeking care and/or services for a family member or friend. I am seeking care and/or services for a client or patient. I am not currently seeking care or services, but I do want to share my past experiences with others by posting a review. I am not currently seeking care or services, but will be in the future and would like for this resource to be available at that time. Other (please specify) Question Title * 4. If you are seeking care and/or services for yourself and/or your loved one, patient, client, etc., please indicate what type of provider you are seeking? Please check all that apply. Short-term Residential Facility Long-term Residential Facility Independent Living Facility Assisted Living Facility Skilled Nursing Facility Continuing Care Facility Continuing Care Retirement Community ICFMR Waiver Home Developmental Center Halfway House Alternative Housing Therapeutic Farm or Facility Senior Housing ADA Compliant Housing Supportive Living Services Physical Rehabilitation Facility Transportation Services - wheelchair and elder-friendly Day Activity Center Day Workshop Supported Employment Home Health Care Hospice Care Cancer Center Dialysis Center Physical Therapy Speech Therapy Occupational Therapy Respite Programs/Services Recreation Facility Recreation Programs/Services Aquatic Facility/Center Care Advisor Legal Services Financial Services Specialty Travel Funeral Home Other (please specify) Question Title * 5. Please check ALL that apply: I have a chronic illness. I have a terminal illness. I am 65 years or older. I have a physical disability. I have a developmental or intellectual disability. I have a serious mental illness. I have a serious injury. I am a caregiver and/or advocate to a loved one or friend with a chronic illness. I am a caregiver and/or advocate to a loved one or friend with a terminal illness. I am a caregiver and/or advocate to an aging loved one or friend. I am a caregiver and/or advocate to a loved one or friend with a physical disability. I am a caregiver and/or advocate to a loved one or friend with a developmental or intellectual disability. I am a caregiver and/or advocate to a loved one or friend with a serious mental illness. I am a caregiver and/or advocate to a loved one or friend with a serious injury. I am legal guardian to an adult with a developmental or intellectual disability. I am legal guardian to an adult with a serious mental illness. I make decisions about care and/or services for my loved one or friend. I am involved in the care of a loved one, but I am not the primary caregiver. I am a professional seeking help for a patient or client. Other (please specify) Question Title * 6. Please check all that apply about reviewing care and/or service providers: I like to read online reviews and find them helpful in making decisions. I like to post online reviews/plan to post online reviews in the future. I prefer to use my laptop or desktop computer to add a review. I prefer to use my cell phone to add a review. I don't mind if review is posted by "anonymous". I do mind if a review is posted by "anonymous". Other (please specify) Question Title * 7. Please answer the following about connecting with others: I would like to connect with others in similar situations. I am not interested in connecting to others in similar situations. Other (please specify) Question Title * 8. Please select your gender: Male Female Question Title * 9. Please select your age range: 18 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 or older Other (please specify) Question Title * 10. PLEASE NOTE: You are only required to enter your CITY, STATE and ZIP CODE. Any additional information will be used for our records only. We will not share your information. CareSpotlight.com will ONLY be serving people in the Continental U.S. Information outside the Continental U.S. will not be used at this time. Thank you. Name: Address: Address 2: City/Town: * State: * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: * Email Address: Done
