Senior Housing Needs Assessment

Full Name Date of Birth Contact Number Current Address

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Type of Residence Own Home Rental Living with Family Assisted Living Other Do you live alone? Yes No Is your home accessible (e.g., stairs, ramps)? Yes No Partially

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Health Conditions or Limitations Do you require assistance with daily activities? Yes No Sometimes Are you taking regular medication? Yes No Do you receive home care or support services? Yes No

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Preferred Location Preferred Housing Type Independent Living Assisted Living Nursing Facility Shared Housing Other Expected Monthly Housing Budget Desired Amenities or Services

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