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Needs Analysis Survey

This Needs Analysis Survey will help us assess your specific needs so we can provide you the resource information best suited for your specific needs.   The responses that you give us are very important, as they are the basis upon which we are able to match you with providers who can assist you. Simply put, our ability to assist you is directly related to the quality of information we receive from you. Finally, because your results will be provided via email and phone we can only help you if you provide us with a valid phone number and  e-mail address. Without this information, we'll be unable to assist you.

Thank you for visiting GrAce Ministries! We'll be happy to assist you in providing our latest resource guide.  Please complete the Needs Analysis survey below

CONTACT INFORMATION

For the person completing this survey . . . please provide the following information.

CONTACT INFORMATION

For the person completing this survey . . . please provide the following information.

 
Name: *
E-mail Address: *
Phone:
Address:
City:  State: Zip:

* Required

 

NEEDS INFORMATION

From the list of choices below, which one best describes your primary need:
(Select one)

Long Term Care Residence
Advisory and/or Consultative Services (e.g. elder law/legal, financial/investment advice, estate planning, long term care planning, care management, family counseling, placement support)

Please provide the desired location for the services) or products) to be provided:
 
City: State:
Zip:    

Please select your preference for where care is to be provided:
(Please select all that apply)
In-Home

Please select any services that you believe are required for the Care Recipient:
(Please select all that apply)

Do you need or want information of the following Consulting / Advisory Services?
(Select all that apply)
 
Do you want a home visit and assessment for your loved one?

Does the care recipient need price quotes and/or more information on any of following?
(Please select all that apply)
Medical Alarms / Personal Help Buttons / Emergency Response

What funding source will be the primary payer for the services or products?
(Please select one)
Private pay
Combination (Private Pay & Medicare)

Many Gracefully Aging services and products are not covered by insurance, Medicare, Medicaid or public assistance. As such, are you willing to pay "out-of-pocket" for part or all of the services you requested?
(Please select one)
How much have you budgeted for these "out-of-pocket" expenses?
(please select one)

 
I have read and accept the attached Terms of Use and hereby authorize GrAce Ministries to submit and share information I have posted on the Site through the needs survey and/or other means to any provider in accordance with the Terms of Use. I recognize that I have been informed throughout this website and through the Terms of Use of all disclosures required by law regarding the business relationship between GrAce Ministries and its participating providers. I further acknowledge that this authorization will remain effective unless I notify GrAce Ministries in writing of the revocation of this Authorization Statement at the address given in the Terms of Use. I further acknowledge that the information provided by me is accurate and complete.
 Yes
No

 

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a 501(c)(3)  nonprofit organization. Copyright © 2007 GrAce Inc,  All Rights Reserved.