General Needs Survey Question Title * 1. How would you rate your overall health? Excellent Good Fair Poor OK Question Title * 2. What type of home do you currently live in? Single Family Mobile Home Apartment/Townhome Senior Independent Apartments Assisted Living Homeless Other (please specify) OK Question Title * 3. Do you feel you have enough money for food, shelter, and clothing expenses? Yes No OK Question Title * 4. Do you have any difficulties paying your utility bills including gas (heat), electric, water, trash, telephone, internet utilities Yes No OK Question Title * 5. Do you have difficulty with transportation to medical care? Yes No OK Question Title * 6. Indicate if you have ever used any of the following services: Elder Law Case Management Respite Care Personal or Attendant Care Adult Day Care Personal Emergency Devices Homemaker Services Minor Home Repair Transportation Services Medicare Counseling Services None of the above OK NEXT