Senior Community Needs Survey
We are working to bring services to seniors in our community, including meal programs and a possible senior center.
Your input matters. All responses are confidential.
About You
1. Age:
55-64
65-74
75-84
85+
2. Living Situation:
Alone
Partner
Family
Other:
3. Area:
Willow Creek
Salyer
Hoopa
Orleans
Hawkins Bar
Burnt Ranch
Other
Meal Needs
4. Would you benefit from access to free meals?
Yes
No
Sometimes
5. Would you like hot meals (on-site)?
Yes
No
Maybe
6. If you answered "yes" to question #4. How often would you benefit from free meals?
Daily
Few/week
Occasionally
Never
7. Would you need meals delivered?
Yes
No
Maybe
8. If you answered "yes" to question #7. How often would you benefit from meal delivery?
Daily
2-4 times a week
1-2 times a week
A few times a month
Only Occasionally
9. Dietary Needs:
Diabetic
Low sodium
Vegetarian
Other
Senior Center
10. Would you attend a senior center?
Yes
No
Maybe
11. If "yes" to question #10. Which activities would you like to attend?
Meals
Social
Exercise
Games
Workshops
Health
Back
Next
12. How often would you visit a senior center?
Daily
Weekly
Monthly
Rarely
Your Needs
13. Are there any other services you might benefit from?
Meals
Health
Support
Paperwork help
Home check-ins
14. Biggest challenges you face?
15. Additional comments or concerns?
Contact Information
Name:
First Name
Last Name
Phone:
Format: (000) 000-0000.
Thank you for helping strengthen our senior community program!
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