If you would prefer, we can call you to complete this survey with you over the phone.  Please contact lgorman@parkwoodmh.com.
Please complete the bottom question to add your name and contact information.

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* 1. Do you identify or belong to any of the following groups? Check all that apply.

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* 2. What is your age group?

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* 3. How would you rate your current level of loneliness

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* 4. Please tell us how many recreation or social programs you usually attend each week: (exercise, trivia, cooking, education, etc.)

  In person (if applicable) Online (Virtual, e.g.: Zoom, facetime, YouTube) Telephone
0-1 time
2-3 times
4 or more times

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* 5. How many times per week do you usually talk to your family?

  In person (If applicable) Online (Virtual, e.g.: Zoom, Facetime)  Telephone Letters
0-1 time
2-3 times
4 or more times

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* 6. How many times per week do you usually talk to your friends?

   In person (If applicable) Online (Virtual, e.g.: Zoom, Facetime) Telephone Letters
0-1 time
2-3 times
4 or more times

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* 7. Are you able to communicate with friends and family online?

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* 8. Would you like training on how to use the internet and social media?

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* 9. Do you have regular access to equipment to access the internet? (iPhone, tablet, computer)

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* 10. Would you like to increase your access to equipment that would allow you to be more active online?

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* 11. Do you get your information about Fairview/Parkwood online?

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* 12. Do your friends and family get information about Fairview/ Parkwood online?

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* 13. Which of the following activities would you be interested in attending online or by telephone? Check all that apply.

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* 14. Which of the following times work for you to participate in a virtual or online activity? Check all that apply.

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* 15. Which of the following video or phone systems do you have access to?

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* 16. Which of the following best describes your relationship to Parkwood?

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* 17. In order for us to contact you and set activities up in the future via phone, mail, or email can you please provide:

0 of 17 answered
 

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