*Needs Assessment Family Questionnaire* CAREGIVING/LANGUAGE & ACCESSING COMMUNITY RESOURCES The following questions help the Alzheimer's Association meet the needs of the community. Your answers will be kept confidential to the Alzheimer's Association. Question Title * 1. Have you or a family member experienced memory loss? Yes No Unsure Question Title * 2. How many hours per day of care giving are you providing to your loved one? Question Title * 3. Do you speak English? Yes No Question Title * 4. What other language(s) do you speak? Question Title * 5. Who are you most likely to confide in when you are concerned about your health? Other (specify below) Community Clinic Church/Synagogue/Other faith based organization Primary Care Physician Senior Center Friend or Family Member Area Agency on Aging Town Social Services Mental Health Professional/Counselor Internet/Online Community Other (please specify) Question Title * 6. How comfortable are you in asking for assistance? Very Comfortable Somewhat Comfortable Not at all Next