Care Connection Needs Assessment Survey

Needs Assessment Survey2023

*requires a response

Below is a list of concerns that could be affecting your quality of life. Please check all that you have had a problem with in the last 12 months.

Medical Issues
Financial Issues
Caregiving
Community Issues
Have you ever used services from Care Connection for Aging Services?
Do you ever go to your local senior center?

Demographics: Please check the boxes that apply to you.

What is your source of transportation? (Check all that apply.)
Where do you go for help and/or needs? (Check all that apply.)
Age
Gender
Martial Status
Are you retired?

Thank you for taking the time to fill out this survey.

If you would like Care Connection to follow up with you on any of the above needs, please call us toll free: 800-748-7826, ext. 241 (website: www.goaging.org) or supply your name and phone number if you would like us to contact you.

Name
Name
First
Last

Your privacy matters to us. Please take a moment to review our privacy policy to understand how we collect, use, and protect your personal information.

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