Service & Support Questionnaire (SSQ)

1)  I am looking for information about services for...  (please select one)
2)  I prefer to receive services:  (check all that apply)
3)  I require assistance with the following tasks:  (check all that apply)
4)  I require assistance with the following household chores:  (check all that apply)
5)  I am able to move around...  (please select one)
6)  I have experienced...  (check all that apply)
7)  In my current care situation, I...  (check all that apply)
8)  I am able to pay for services with my own money...  (please select one)
9)  My health insurance is issued by...  (check all that apply)
10)  I have the following:  (check all that apply)
11)  Some of my most pressing needs are...  (check all that apply)
12)  I need assistance with other matters such as...  (check all that apply)
13)  Age:  (please select one)
14)  County of Residence * :