Arts on Prescription/Creative Aging Questionnaire

Arts on Prescription / Creative Aging Questionnaire

Supporting Collaboration and Growth in Creative Aging and Arts on Prescription Programs Across North Carolina
CAN-NC is creating a centralized statewide resource to highlight Creative Aging programs and Arts on Prescription pilot projects happening across North Carolina. This questionnaire is designed to gather key information from arts, aging service providers, and healthcare organizations about current programs, partnerships, and opportunities for collaboration. The information you share will not only support cross-sector learning and strengthen the field—it will also help community members, potential partners, and funders more easily discover and connect with you and your work. Thank you for contributing to this important effort.
Company Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What type of organization is this?*

Arts (gallery, museum, dance studio, theater, etc)Aging (independent living, assisted living, skilled care, adult day care, home care/home health, active adult center, etc)Healthcare (hospital, primary care, cancer center, clinic, etc)Other
Name of Contact*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
What types of creative programs do you offer?*

Painting/DrawingDigital ArtsPottery/ClaySinging/ChorusJewelry/BeadingFashionMusicDrama/TheaterCooking/Culinary ArtsDance/MovementWriting/PoetryGardening/HorticultureTai Chi/YogaWeaving/Fiber ArtsWoodcraft/carving/burningFilm/PhotographyCrochet/Knitting/QuiltingNone of theseOther
Are you offering a social prescribing/arts on prescription pilot?*

YesNo
If yes, please tell us more about the pilot including a brief summary, who you are partnering with, and the dates or anticipated dates of the project. (optional)
What Quality of Life and/or Social measures do you track?*

Reduced loneliness and isolationSelf-rated health statusMeaning and purposeOverall life satisfactionEmotional resilienceIncreased social network/participationSense of community belongingNone of theseOther
What Cognitive, Artistic and/or Mental Health measures do you track?*

Reduced symptoms of depression & anxietySelf-reported mental sharpnessImproved moodImproved attention & memorySense of controlIncreased sense of purposeSustained learning & masteryGreater self-confidence/self-efficacySkill developmentArtistic confidenceIdentity shift to "artist" from "participant"None of theseOther
What Physical Health, Well-being, and/or Healthcare use measures do you track?*

Reduced primary care visitsBetter sleep qualityIncreased activity levelsImproved medication adherenceReduced lonelinessReduced stressReduced reliance on emergency/healthcare crisis servicesNone of theseOther
Do you regularly include a culminating public presentation, exhibition, or celebration as part of your program? If yes, please describe what this involves? *
Are you interested in collaborating with others?*

YesNo
How is your program funded? Select all that apply. (Optional)

Arts Council or Arts OrganizationHealthcare ProviderFederal Health Insurance [Medicare, Medicaid, CHIP, TRICARE, Veteran's Health Administration (VHA) programs, and Indian Health Service (IHS)]Health Insurance CompanyGovernment GrantFoundationSponsorshipPrivate PayOther
Is there anything else you would like to share? (Optional)
Should be Empty:

Arts on Prescription / Creative Aging Questionnaire