Round Table Discussion
Filling out this survey is voluntary. The information captured in this survey will help us understand current needs of seniors and inform us on how we need to improve programs and services. Happy at Home Halifax is a new program, funded by Employment and Social Development Canada. No identifying information will be shared and will be kept confidential.
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Age
Ex:23
Gender
Please Select
Male
Female
N/A
Do you live _________ ?
Alone
With family/roomate
Assisted Living
What challenges have you faced in accessing needed services or information in the past 6 months?
Do you know where to call for new services?
What would help to improve your quality of life right now?
Do you have any suggestions for a service or program needed to help seniors?
Can we follow up with you?
Phone
Email
Mail
Demographics
What annual income range do you fit in?
Below $10,000
$10,000 - $24,999
$25,000 - $49,999
$50,000 - $70,000
Above $70,000
Please check all that apply to you:
First Nations
Metis
Inuit
African Canadian
Black
Caucasion
Asian
Caribbean
Filipino
Living in rural or remote atea
Senior with disability
2SLGBTQIA+
Other
Do you identify as a newcomer?
Yes
No
What is your official language of communication?
Thank you for your time in completing this survey.
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