Is your home ready for Senior Care?

Take our 3- minute survey to see if there are possible improvements

1. Who are you completing this for? *

Myself

Spouse/ Partner

Parent

Other loved one

2. In the past 30 days, have any of these been difficult? *

Bathing, Dressing, Grooming

Cooking, cleaning, household tasks

Mobility or getting around safely

None

3. Which best describes the current health situation? *

Frequent doctor or hospital visits

Medication reminders or management needed

Chronic condition requiring monitoring

None

4. Have any of these concerns come up recently *

Falls or near-miss accidents

Forgetfulness causing unsafe situations

Wandering or disorientation

None

5. Have you noticed any of the following? *

Feeling lonely or isolated

Loss of interest in activities

Difficulty managing stress or emotions

None

6. For family or caregivers, does any of this feel true? *

Feeling overwhelmed or burned out

Difficulty providing consistent care

Need for respite or rest

None

7. Which statement best fits where you are right now? *

Just gathering information

Open to learning about support

Actively looking for help

Urgent need for assistance

8. Which best describes the current care situation? *

Fully independent, no help needed

Some help from family or friends

A recent health event or hospitalization

9. What is the most important goal right now? *

Staying safely at home

Reducing stress on family caregivers

Improving daily quality of life

Planning ahead for future care needs

10. What has made this decision difficult so far? *

Not sure if help is really needed yet

Unsure what type of care is appropriate

Cost or affordability concerns

Not knowing who to trust

11. If help were needed, which option feels most comfortable? *

Occasional help (a few hours per week)

Regular support (several days per week)

Daily or full time care

Just gathering information for now

12. Is there anything else you’d like us to know about your situation?

“You may include concerns, urgency, questions, or anything that would be helpful for us to understand.”

After answering the questionnaire, please proceed to fill in your contact details (Name, Email, and Phone Number) so we can reach you easily for the next steps.

First Name *

Last Name *

Email *

Phone