Haines Assisted Living Survey 2025 Please help us understand the needs of the elders in our community by completing this survey Your feedback will help determine the future of Haines Assisted Living Name * First Name Last Name 1. Your Age Under 65 65-74 75-84 over 85 Caring for someone over 65 2. Where do you currently live? At home independently At home, with family or help Senior Housing Other 3. Do you use any of these services? No Yes, please check all that apply Senior Center meals Home delivered meals Cornerstone Home Health Care Southeast AK Independent Living Other 4. Do you require assistance with any daily activities? No Yes, please check all that apply Bathing Dressing Eating Taking medications Other 5. Do you have mobility issues or use any of these? No Yes, please check all that apply Cane Walker Wheelchair Difficulty managing stairs Other 6. Where do you see yourself living if you cannot live independently? Living with family Assisted Living facility Leaving Haines Other 7. Would you consider Haines Assisted Living? Yes, probably soon Yes, maybe later No If not, why not? 8. Do you have any concerns when considering assisted living? Please check all that apply Cost I'd like to know how Medicaid can help cover the cost Privacy Level of care Lack of independence Other 9. What are your financial plans for long term care? Social Security Long term care insurance Medicaid Pension/Retirement/Savings Other 10. What services could we provide to help you age in Haines? Adult daycare Respite care (Available at Haines Assisted Living, this provides temporary care for a person unable to care for themselves, allowing their usual caregivers to take a break) Other 11. Have you ever visited Haines Assisted Living? Yes No 12. Would you like a tour of the rooms? Yes please! No thank you Want to know more? Yes please! Phone (###) ### #### Email Mailing Address Date MM DD YYYY Thank you!