Needs Assessment Family Questionnaire

CAREGIVING/LANGUAGE & ACCESSING COMMUNITY RESOURCES

The following questions help the Alzheimer's Association meet the needs of the community. Your answers will be kept confidential to the Alzheimer's Association.

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* 1. Have you or a family member experienced memory loss?

Yes

Unsure

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* 2. How many hours per day of care giving are you providing to your loved one?

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* 3. Do you speak English?

Yes

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* 4. What other language(s) do you speak?

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* 5. Who are you most likely to confide in when you are concerned about your health?

Other (specify below)

Community Clinic

Church/Synagogue/Other faith based organization

Primary Care Physician

Senior Center

Friend or Family Member

Area Agency on Aging

Town Social Services

Mental Health Professional/Counselor

Internet/Online Community

Other (please specify)

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* 6. How comfortable are you in asking for assistance?

Very Comfortable

Somewhat Comfortable

Not at all