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Take Our Quiz
First name
Last name
How much help do you need with everyday tasks like getting dressed, bathing, or grooming?
*
None
Some
A lot
Do you need any support with managing your medications or health treatments?
*
Yes
No
Are there any specific tasks related to personal care that you find challenging?
*
Yes
No
Are you currently receiving any medical treatments or therapy for health conditions or disabilities?
*
Yes
No
Do you have any long-term health conditions that require ongoing care or management?
*
Yes
No
Are there any health-related tasks or appointments you find difficult to manage on your own?
*
Yes
No
How often do you get involved in social activities or go out with friends?
*
Regularly
Sometimes
Rarely/Almost Never
Do you ever feel isolated or find it hard to connect with others socially?
*
Yes
No
Are there any hobbies or interests you'd like to pursue but feel you need support with?
*
Yes
No
Are you currently working or studying?
*
Yes
No
Do you feel you need help finding work or managing your studies?
*
Yes
No
Are there any specific career or educational goals you're working towards?
*
Yes
No
Do you sometimes need assistance getting to appointments or running errands?
*
Yes
No
Are you able to travel independently by public transport or drive yourself?
*
Yes
No
Do you face any barriers when it comes to getting around in your community?
*
Yes
No
Are there any devices or equipment you use to help with tasks like moving around or communicating?
*
Yes
No
Have you received training or support to use assistive technology?
*
Yes
No
Are there any specific devices or tools you'd like to learn more about?
*
Yes
No
Do you need any support with where you live or how you manage your home?
*
Yes
No
Do you live alone, with family, or with caregivers?
*
Alone
With Family
With Caregivers
Are there any aspects of your living situation that you'd like to change or improve?
*
Yes
No
Are there times when you need help managing your emotions or behavior?
*
Yes
No
Have you ever received support or counseling to help with these challenges?
*
Yes
No
Are there any specific strategies or techniques you'd like to learn to help you cope better?
*
Yes
No
Do the people who help care for you sometimes need a break?
*
Yes
No
Have you ever had a short break from your usual care routine?
*
Yes
No
Do you feel your caregivers have enough support themselves?
*
Yes
No
Do you feel you need support that respects your cultural background or language?
*
Yes
No
Do you find it easy to communicate with service providers in your preferred language?
*
Yes
No
Are there any cultural traditions or customs important to you that you'd like support to maintain?
*
Yes
No
Are there any legal matters or financial issues you need help with?
*
Yes
No
Have you ever received advice or assistance with these matters?
*
Yes
No
Are you aware of any financial support or benefits you might be entitled to?
*
Yes
No
Do your family members or caregivers sometimes need support themselves?
*
Yes
No
Are they fully aware of your needs and how best to support you?
*
Yes
No
Do you feel you have enough support from your family or caregivers?
*
Yes
No
Email
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