Senior-Adult Day Care Center Survey Question Title * 1. Do you understand the definition of senior-adult daycare? YES NO Question Title * 2. Would someone in your circle of family or friends use the services of a senior-adult daycare center? YES NO Question Title * 3. If so, how many days per week? 1 2 3 4 5 Question Title * 4. Half days or full days? HALF FULL Question Title * 5. What do you think is a fair price for a half day of services? $10 $20 $30 $40 $50 Question Title * 6. If the costs were not covered by insurance or other programs, would you be willing to pay out of pocket? YES NO Question Title * 7. What types of services would yo like to see for your loved one at a senior-adult day care center? Check the boxes below. Social interaction Medication management Memory exercises Bathing Transportation to appointments Crafts and games Meals and snacks Guest speakers Occupational Therapy Physical Therapy Question Title * 8. Optional: Contact information Name Address City/Town State/Province ZIP/Postal Code Phone Number Question Title * 9. Leave any other comments here below. Done