Faith Based Needs Assessment | The Senior Source

Name*

First Last

Phone

Email*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name of Faith Based Community:*

Faith Based Leader:*

Direct contact person/community engagement:*

Give a brief synopsis of your community and congregation:*

Specific demographics including age, marital status, race/ethnicity, gender:*

What percentage are caring for caregivers:*

Age of the average caregiver and recipient:*

Primary Ailments:*

Percentage of people with a cognitive impairment:*

Percentage with chronic illness, please specify prevalence of chronic disease/s:*

Type of outreach/education the church, temple, synagogue or mosque provides:*

Partnerships already developed/being served/assisted by what orgs:*

How do you think TSS/CSP can assist to meet the needs of your community?*

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