Needs Assessment Service Provider Questionnaire

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.

Question Title

* 1. Which of the programs and services offered by the Alzheimer's Association have you used or referred families to?

24/7 Helpline

Family Caregiver/Health Care Provider Education

Care Consultation

Support Groups

Medic Alert®+ Alzheimer's Association Safe Return®

None of the above

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* 2. Do you have information at your place of business about Alzheimer's disease or the Alzheimer's Association?

Yes

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* 3. How can the Alzheimer's Association do a better job of marketing our mission, programs and services?

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* 4. From your point of view, what do you consider the greatest unmet or met need(s) of caregivers that confide in or consult you?

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* 5. How can we help you serve the needs of individuals with dementia?

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* 6. Do you see clients that have Alzheimer's disease or another type of dementia who may be in need of our support services?

Yes

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* 7. Please provide your contact information, to receive updates about programs and services offered by the Alzheimer's Association:

First Name

Last Name

Title

Company

Address

City

State

Zip Code

Phone

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* 8. What is your preferred method of contact?

Phone

Mail