Needs Assessment
Please check all boxes that apply for the following questions:
1. Things I need help with:
Need Help Now
Currently Receive Help
Might Need Help in the Future
Care for a parent or family member
Finding Friends/social activites
Understanding Medicare
Affordable Housing
Legal Affairs/ Advance Care Planning
Home Repair & Yard Maintenance
Managing Medications
Emotional support/Counseling
Eating, bathing and dressing
Housekeeping, shopping, errands and chores
Managing Finances/filing taxes
Subsidized housing
Finding an M.D./ health provider
Adult Day Care/ respite care
Care planning/ service coordination
Visiting service/ telephone reassurance
Senior Center services
Educational services & supports
Information & referral services
Other please state here:
Your answer
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