Client Survey

Please take a few minutes to complete this survey on the required eldercare services. Omega ElderCare Services, LLC welcomes your feedback, and your answers will be kept confidential. Thank you for your participation. Contact Omega ElderCare Services to discuss your needs.

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- Step 1 of 6

Client Survey

Please take a few minutes to complete this survey on the required eldercare services. Omega ElderCare Services, LLC welcomes your feedback and your answers will be kept confidential. Thank you for your participation.

Are you currently a caregiver or guardian of a senior adult? *

The required services are for which individual(s)? *

Parent
Other Relative
Friend
Self
Client

Based on your observations, what is the current state of the senior adult’s health? *

Well
Good
Some chronic issues (E.g. Arthritis, Diabetes, High Blood Pressure)
Poor

Age of the individual(s) for whom services are required? *

Under 60
60-70
70-85
85-200

How do you normally obtain care giving services? *

Enter Your Response Above

How often has the senior adult visited a doctor(s) within the past year? *

1 - 3 Visits
4 - 6 Visits
7 - 12 Visits
More than 12 Visits

What kind of service(s) do you need Omega ElderCare to provide? (Please check all that apply) *

Consultation
Coordination of Support Services
Care Management
Discharge Planning
Housing Arrangements
Cleaning Services
Referral to Health Care Providers
Transportation
Respite Care
Other (if other see below)

If other, please briefly describe

If you require an initial consultation, how would you like to do so?

In Person
Via Telephone
Via the Internet

Do you have a specialist? If so, what is that person’s specialty?

If you require a health care specialist for referral purposes, what type of specialist do you require?

If you are unsure of what type of health care specialist is required, is this something that you would like to discuss during the initial consultation? *

Which service(s) do you require? (Please check all that apply) *

Basic Activities of Daily Living
Instrumental Activities of Daily Living
Grocery Shopping
Investigating Housing Options
In-Home Safety Assessment
Long-Term Care Planning
Drafting of Medical (Health Care Proxy, Living Will)
Finances
Review of Entitlement Programs (Medicare, Medicaid and SSI)
Transportation
Nutrition
Obtaining Home Health Aides
Coordination of delivery/maintenance of medical supplies/equipment (Assistive Devices)
Recreational/Social Activities
Counseling & Therapy
Support Group for Caregivers
Making Final Arrangements
Other

How would you rate the assistance that was received from the Primary Care Provider (PCP) in the past 2 years? *

Outstanding
Good
Adequate
Needs improvement
Poor
N/A

How would you rate the professionalism of the PCP on a scale of 1 to 10?

Selected Value: 1

Please Use Sliding Bar (1 is Very Poor 10 Is Exceptional)

How would you rate the quality of service provided by the PCP on a scale of 1 to 10?

Selected Value: 1

Please Use Sliding Bar (1 is Very Poor 10 Is Exceptional)

What did you find most displeasing about the services provided by the PCP?

What did you most appreciate about the services provided by the PCP?

How would you rate the assistance that was received from the specialist in the past 2 years? *

Outstanding
Good
Adequate
Needs improvement
Poor
N/A

How would you rate the professionalism of the specialist on a scale of 1 to 10?

Selected Value: 1

Please Use Sliding Bar (1 is Very Poor 10 Is Exceptional)

How would you rate the quality of service provided by the specialist on a scale of 1 to 10?

Selected Value: 1

Please Use Sliding Bar (1 is Very Poor 10 Is Exceptional)

What did you find most displeasing about the services provided by the specialist?

What did you most appreciate about the services provided by the specialist?

To what extent will the senior adult be included in the health care decision making process? *

Fully
Somewhat
Not at All

Have you prepared a list of contacts, medicines and instructions in case of emergencies? *

Please list any area(s) where services/assistance is required which were not listed on this survey.

Please share any additional comments.

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email *

How would you like someone to contact you regarding your responses on this survey? *

In Person
Via Telephone
Via the Internet

Would you like to participate in a monthly support group for caregivers? *

Yes
No
Need More Information

What value would you place on a monthly support group meeting that may include social activities such as dinner and a concert? *

$50-$75
$75-$100
$100-$150
$150-Up

You Have Reached The End Of This Survey

Thank you for taking the time to complete our survey. All responses are confidential. We rely on your feedback to help us improve our services. Your input is greatly appreciated.

Omega ElderCare Services, LLC
697 3rd Ave., Suite 744
New York, New York 10017
Telephone: 646-941-9739
Facsimile: 646-619-4533

(646) 941-9739

[email protected]

Thank you for taking the time to complete our survey. All responses are confidential. We rely on your feedback to help us improve our services. Your input is greatly appreciated.

Client Survey

Client Survey

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