Skip to content

JP@Home Member Intake Form

All responses will be kept strictly confidential. Only aggregate data will be shared with Ethos staff and JP@Home Advisory Council members.
1.First Name(Required.)
2.Last Name(Required.)
3.What is your email address?(Required.)
4.Have you ever served in any branch of the United States military, or not?(Required.)
5.

Are you White, Black or African-American, American Indian or Alaskan Native, Asian, Native Hawaiian or other Pacific Islander, or some other race?

(Required.)
6.Are you Mexican, Mexican-American, Chicano, Puerto Rican, Cuban, Cuban-American, or some other Spanish, Hispanic, or Latino Group?(Required.)
7.How many persons are included in your household?(Required.)
8.Which of the following best describes your current relationship status?(Required.)
9.Do you consider yourself to be:(Required.)
10.Home Ownership(Required.)
11.Home Type(Required.)
12.What is the highest level of school you have completed or the highest degree you have received?(Required.)
13.Which of the following categories best describes your employment status?(Required.)
14.Which of the following best describes your current or most recent occupation?(Required.)
15.What is your approximate average household income?(Required.)
16.How often do you use the internet?(Required.)
17.What is your most preferred communication method(s) from JP@Home? (Select all that apply)(Required.)
18.What is the best time or day of the week for you to attend meetings of JP@Home members?  (Select all that apply)(Required.)
19.What activities are you interested in? (Select all that apply)(Required.)
20.Please tell us how important the following are to you as you age:(Required.)
High Priority
Very important
Somewhat Important
Not Important
Home Repair and Maintenance
Finding Information About Resources for Senior Citizens
Finding Information About Long-Term Care Services and Insurance
Organized Trips (e.g., Trips to Movies, Museums, Plays, Casinos, Historical Sites)

Finding Information About Community Safety

 

Transportation to Shopping, Religious Services, Visiting Friends, Etc.
Finding and Coordinating Services, Visiting Friends, Etc.
Keeping the House Clean
Social Opportunities (e.g., Book Clubs, Bridge Games, Sewing Clubs, Social Events)
Opportunities for Exercise (e.g., Walking Clubs, Exercise Classes, Water Aerobics)
Installing Home Safety Equipment
Finding Someone to Check my Home for Things that Might Cause Me to Fall
Keeping Track of Money and Bills
Prefer not to answer
21.How do you get around? (Check all that apply)(Required.)
22.In general, how would you rate your overall health?(Required.)
23.Does your health status interfere with what you would like to do?(Required.)
24.Emergency Contact(Required.)
25.How did you hear about JP@Home? (Select all that apply)(Required.)