Care for Elders and People with Disabilities  Survey

1.Age range?

under 50

50-65

65+

80+

2.Living with a disability?

Yes

No

Unsure

3.Connected to a community? Which one?

Other (please specify)

4.Are holistic needs being met? (emotional, physical, mental or spiritual)

5.What kind of help/support is needed at home?

6.What kind of help/support is needed in community?

7.Supports or services that currently help or work well? (...in home? in community?)

8.Supports/services that need improvement? (...at home? in community?)

9.What are your top 3 services?
(If stuck for inspiration, please see Q15. APPENDIX for a list of services/supports)

1.

2.

3.

10.What are 3 services you would like to see?
(If stuck for inspiration, please see Q15. APPENDIX for a list of services/supports)

1.

2.

3.

11.Who do you go to when you need something? (...at home? what about in community?)

12.In a perfect world, what would holistic care look like? (emotional, physical, mental or spiritual)

13.Do you have any other comments? concerns? things you would like to add?

14.OPTIONAL: Contact Details for Walmart Draw

Name

Email Address

Phone Number

Care for Elders and People with Disabilities