Homecare Quiz Please Fill Out Below Form Home Care Quiz 1. Who needs Senior Care?(Required) Myself My Spouse My Parent A Loved One A Friend 2. What is their age range?(Required) 60s 70s 80s 90s 100 or older! 3. Where do they live?(Required) Nassau Suffolk Queens Brooklyn The Bronx Manhattan Staten Island Westchester 4. What are their living arrangements(as of right now) ?(Required) Home(lives alone) Home(with family) Assisted Living Nursing Home / Rehab Facility 5. How are they getting around?(Required) Independently Cane Walker Wheelchair Bedridden 6. Do they need assistance with any of the following?(Required) Medication Reminders Bathing Toileting Companionship Houskeeping Meal Preparation Alzheimer’s and Dementia Care Parkinsons Carre Social Actives EVERYTHING! 7. Have they experienced any of these behaviors?(Required) Wandering Hallucinations Sundowning Agressiveness Irritability Forgetfullness None of the above All of the above 8. What type of senior care are you seeking to learn more about?(Required) Private Homecare Community Medicaid Assisted Living Placement Concierge Private Nursing Transportation All of the above 9. What is your preferred avenue of communication?(Required) Phone call Text Email 10. How did you hear about us?(Required) Google Hospital Rehab Facility Hospice Aging Care Managers Social Worker Website Social Media 11. Have you seen that sometimes prescription medicine hasn't been taken? Yes No Not Sure 12. Is the idea of bringing in care (companionship) viewed as a sign of strength and desire to maintain independence? Yes No Not Sure 13. Do you sometimes feel that just having a friend to talk to would brighten your day? Yes No Not Sure 14. Do you believe 1-on-1 companionship tailored to specific goals is important? Yes No Not Sure 15. Are you noticing difficulty with keeping track of appointments? Yes No Not Sure 16. Have there been behavioral change ( mood swings, hiding things, pacing, withdrawing from activities that you used to enjoy) Yes No Not Sure 17. Have you suffered an injury or illness or is moving around becoming difficult? Yes No Not Sure 18. Do you or your loved one want to remain in your own home? Yes No Not Sure 19. Are you concerned that your family caregivers are giving up too much in order to provide all of the care you need? Yes No Not Sure 20. Do you or your loved one need help getting to doctors appointments or to go shopping? Yes No Not Sure Name(Required) First Last Phone(Required)Email 87085 Friends For Life Homecare- a family team both in the office and in the community! KM - IG Carousel Here? (KM – are we keeping the other sections? Why FFL, Leadership Team from previous site?)