If you prefer to complete this survey by phone with an HSRC staff member, please call 707-443-9747, ext 1267.

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* 1. Have you ever utilized any of the following HSRC programs or services? (check all that apply)

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* 2. What type of challenges do you currently face and/or anticipate facing in the future as you age?
Please check 3 or less current challenges AND 3 or less likely challenges.

  Currently a challenge for me Not a current issue, but likely will be
Nutrition / Meals
Technology
Transportation
Recreation / Activities
Social Isolation
Housing
Home Repair / Upkeep
Medical Access / Personal Care
Respite / Support Groups
Counseling / Therapy

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* 3. What is your current Zip code?

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* 4. What is your current living situation?

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* 5. Does this living situation meet your needs?

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* 6. If your current living situation does NOT meet your needs, how would you like your situation to change?  What would be ideal?

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* 7. How secure are you that your income will meet your basic living and medical expenses in the next year?

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* 8. Do you plan to live on the North Coast (Humboldt County and surrounding areas) for the foreseeable future?

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* 9. What is your gender?

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* 10. What is your age?

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* 11. Which of the following best describes you?

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* 12. If you would like to give us additional input, please provide your contact information.  Thank you.

0 of 12 answered
 

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