Survey Form

1
Hi. To get started, can you tell us who is it you are researching senior living for?* This field is required.
Myself
A Loved One
2
Please tell us about your current living situation.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
3
Alright, now let's talk about why you think it might be time for you to consider a move to an assisted living community.* This field is required.You can choose more than one.
It Might Be Time to Consider Downsizing.
I am Concerned that My Care Needs are not Being Met.
I am Worried About a Recent Change (e.g., Loss of a Partner, an Injury, a Medical Diagnosis).
I am Worried About Loneliness or Isolation.
I am Feeling a Little Overwhelmed and Could Use Some Help.
I Worry About Safety Because of Health or Memory Issues.
4
Do you think having assistance with any daily tasks may be helpful in your day?* This field is required.You can choose more than one.
Getting Dressed
Restroom Assistance
Personal Hygiene Routine
Assistance with Showering/Bathing for Safety Reasons
None of These
I'm Not Sure
5
Do you have any trouble managing and taking medications?* This field is required.
YESNO
6
Do you have any trouble walking?* This field is required.
YESNO
7
What activities would you like to fill your day with?* This field is required.You can choose more than one.
A Cup of Coffee or Tea
A Walk or Other Physical Activity
A Good Meal
Connecting with Friends and family
Being with Pets
Being Outdoors
Spiritual or Faith-Based Activities
TV, Movies or Music
Quiet Time on My Own
Other Interests or Hobbies
8
Other interests or hobbiesPlease specify
Huge
Large
Normal
Small
Ok
Ok
9
Are there any medical conditions or diagnoses that cause concern or need management?* This field is required.You can choose more than one.
None
Yes, But I Manage This on My Own
Yes, and I Need Occasional Assistance
Yes, I need Daily or Regular Access to Medical Care
I'm Not Sure
10
Are you aware of changes in memory and/or thinking?* This field is required.
YESNO
11
How open-minded are you about considering a senior living community?* This field is required.
I’m Open to It
I Need to Talk About it More and Get More Information
This would be Difficult
I'm Not Sure
12
Are you financially prepared for a move?* This field is required.
YESNO
13
Are other family members or friends helping with this decision?* This field is required.
YESNO
14
Are you interested in talking with an expert at The Arbors/Ivy about options that might be a good fit for you?* This field is required.
YESNO
15
How old is your loved one?* This field is required.
55-65
66-75
76-85
Older
16
Please you tell us about your loved one's current living situation.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
17
Alright, now let's talk about why you think it might be time for your loved one to consider a move to an assisted living community.* This field is required.You can choose more than one.
It Might be Time to Consider Downsizing.
I am Concerned That His/Her Care Needs are Not Being Met.
I am Worried About a Recent Change (e.g., Loss of a Partner, an Injury, a Medical Diagnosis).
I am Worried About His/Her Loneliness or Isolation.
I think He/She is Feeling a Little Overwhelmed and Could Use Some Help.
I Worry About His/Her Safety Because of Health or Memory Issues.
18
Does your loved one need help with any of these personal care activities?* This field is required.You can choose more than one.
Getting Dressed
Restroom Assistance
Personal Hygiene Routine
Assistance with Showering/Bathing for Safety Reasons
None of These
I'm Not Sure
19
Is he/she having trouble managing and taking medications?* This field is required.
YESNO
20
Does he/she have any trouble walking?* This field is required.
YESNO
21
What activities would you like to fill his/her day with?* This field is required.You can choose more than one.
A Cup of Coffee or Tea
A Walk or Other Physical Activity
A Good Meal
Connecting with Friends and Family
Being with Pets
Being Outdoors
Spiritual or Faith-Based Activities
TV, Movies or Music
Quiet Time
Other Interests or Hobbies
22
Other interests or hobbiesPlease specify
Huge
Large
Normal
Small
Ok
Ok
23
Are there any medical conditions or diagnoses that cause concern or need management?* This field is required.You can choose more than one.
None
Yes, But They Manage This on Their Own
Yes, and He/She needs Occasional Assistance
Yes, He/She Needs Daily or Regular Access to Medical Care
I'm Not Sure
24
Do you notice changes in his/her memory and/or thinking?* This field is required.
YESNO
25
How open-minded is your loved one about considering a senior living community?* This field is required.
He/She is Open to It
I Need to Talk About it More and Get More Information
This Would Be Difficult
I'm Not Sure
26
Is your loved one financially prepared for a move?* This field is required.
YESNO
27
Are other family members or friends helping you with this decision?* This field is required.
YESNO
28
Are you interested in talking with an expert at The Arbors/Ivy about options that might be a good fit for your loved one* This field is required.
YESNO
29
Ok, someone will reach out with more information. Tell us how to get in touch:
30
Name* This field is required.
First Name
Last Name
31
Email* This field is required.
example@example.com
32
Phone Number* This field is required.
Please enter a valid phone number.
33
What's Your Preferred Contact Method?* This field is required.You Can Choose More Than One
Text/Email
Phone Call
34
Please Choose a Location You Would be Interested in* This field is required.Please Choose One
Amherst
Chicopee
Dracut
Ellington
Greenfield
Stoneham
Taunton
Watertown
Westfield
35
How old are you?* This field is required.
55-65
66-75
76-85
Older
Should be Empty: