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Needs Assessment
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Needs Assessment
Please fill out the form below to help us better-understand your needs and how we can help you most.
Step 1 of 2
50%
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
Email
I need care for:
*
Myself
Friend/Family
I need help because:
*
Recent Hospital Stay
Stroke
Chronically Ill/Disabled
Alzheimers/Dementia
Traumatic Brain Injury
Diabetes
Other
Check any that apply.
Other:
Please describe your situation.
I need help during these times:
*
Morning
Afternoon
Evening
Night
Check all that apply.
I currently receive some help from:
*
Family Member
Friend(s)
Volunteer
Neighbor
No one
Check all that apply.
I need assistance with:
*
Walking
Getting Up
Bathing
Dressing
Preparing Meals
Feeding
Using the Restroom
Transportation
Housekeeping
Companionship
Check all that apply.
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Helpful
Links
Goodsearch
WV Bureau of Senior Services
Nat’l Institute of Senior Centers
AARP
Nat’l Council on Aging
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Lewis Co. Senior Center
