The Home Helpers - Community Service Survey

1. Hello,
Thank youfor takingthe time tocomplete the surveyinformationasprovidedtoyou. Please note this
surveyonlytakesabout20 minutestocomplete.Allinformationprovidedwill be keptanonymousand
confidential.
The purpose of thissurveyis for tworeasons.One is to gather informationregardingcommunity andat-
home services thatyouare currentlyusingandthe secondpurpose istoknow if you are in needof a
service orresource that youare notcurrentlyusing.
Our goal is to assistyou and/oryour caregiverwithservicesandresourcesthatwill helpimprove overall
health,well-beingandqualityof life. If we are notable to provide youwithaneededservice we willhelp
to connectyouwiththat service where possible.
In orderto betterassistyouwithyourneeds,please complete the enclosedsurveywithareturnphone
numberor email forfollowupandThe Home Helperswill contactyouforfurtherdiscussionbasedon
your needs.
Thank youfor takingthe time tocomplete thissurvey.The Home Helperslookforwardto meetingwith
youfor furtherdiscussioninhowwe maybe of assistance toyou.
WithWarm Regards,
The Home Helpers (AlisonandAlex)
Telephone:705-533-1304
Email: baynhamab@gmail.com

2. Where do you live?
⃝ Townof Midland
⃝ Townof Penetanguishene
⃝ Townof Wasaga Beach
⃝ Townof Elmvale
⃝ Townshipof Tiny(please specify)
⃝ Townshipof Tay (please specify)
What are your current livingarrangements?
⃝ Do you live independentlyinyourownhome
⃝ Do youlive withfamily
⃝ Do youhave assisted-livingarrangements
⃝ Do youin live in a long-termcare facility
⃝ Other
Please check the applicable box below
⃝ A seniorcitizen
⃝ A caregiveronbehalf of a senior citizen
⃝ A familymemberonbehalf of another
⃝ A caregiveronbehalf of another
⃝ Other
What servicesdo you currentlyhave? Please listbelow
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Are these services adequate to your needs?
⃝ YES
⃝ NO (If youansweredNOplease provide detailsbelow)
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3. Do you needhelpwith any ofthe followingtasks? (Checkall that apply)
⃝ Grocery Shopping
⃝ Personal Transportation
⃝ PreparingMeals
⃝ TakingMedication
⃝ PickingupMedicationfromthe Pharmacy
⃝ Banking
⃝ FillingOutForms
⃝ PetCare
⃝ CollectingMail orParcels
⃝ AccessingHealthServices
⃝ AccessingSocial Services
⃝ Yard Care
⃝ House Cleaning
⃝ Other
What do you enjoydoing inthe community?
⃝ Go for walksand/or car rides
⃝ Church Outings
⃝ Go to the Library
⃝ AttendPublicEvents
⃝ Sportsand/or Recreation
⃝ VisitwithFamilyorFriends
⃝ Go Shopping
⃝ PlayCards/Bingo
What do you enjoydoing at home and do you require assistance?
(suchas puzzles,reading,cookingetc..) Please listbelow:
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Please describe your level ofmobility(Checkall that apply)
⃝ I can walkunassisted
⃝ I use a wheelchairorsimilarassistive device
⃝ I use a cane or walker
⃝ Doesnot apply
⃝ I prefernotto say
How do you accesstransportation?
⃝ Personal Vehicle
⃝ PublicTransit
⃝ Taxi
⃝ FriendsorFamily
⃝ Walkingor biking