Homecare Quiz
Please Fill Out Below Form

Home Care Quiz

1. Who needs Senior Care?(Required)
2. What is their age range?(Required)
3. Where do they live?(Required)
4. What are their living arrangements(as of right now) ?(Required)
5. How are they getting around?(Required)
6. Do they need assistance with any of the following?(Required)
7. Have they experienced any of these behaviors?(Required)
8. What type of senior care are you seeking to learn more about?(Required)
9. What is your preferred avenue of communication?(Required)
10. How did you hear about us?(Required)
11. Have you seen that sometimes prescription medicine hasn't been taken?
12. Is the idea of bringing in care (companionship) viewed as a sign of strength and desire to maintain independence?
13. Do you sometimes feel that just having a friend to talk to would brighten your day?
14. Do you believe 1-on-1 companionship tailored to specific goals is important?
15. Are you noticing difficulty with keeping track of appointments?
16. Have there been behavioral change ( mood swings, hiding things, pacing, withdrawing from activities that you used to enjoy)
17. Have you suffered an injury or illness or is moving around becoming difficult?
18. Do you or your loved one want to remain in your own home?
19. Are you concerned that your family caregivers are giving up too much in order to provide all of the care you need?
20. Do you or your loved one need help getting to doctors appointments or to go shopping?
Name(Required)
Friends For Life Homecare- a family team both in the office and in the community!
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(KM – are we keeping the other sections? Why FFL, Leadership Team from previous site?)