Have you've been diagnosed with one or more chronic health conditions, ie. diabetes, congestive heart failure, arthritis? *

Do you often feel lonely, depressed or lack companionship? *

Does anyone in your life talk to you in a threatening way, force you to give them money/sign papers, limit your daily activities, touch you without consent, or harm you? *

Are you in need of items or products that increase, maintain or improve functional capabilities such as medical devices, speech recognition software, hearing aids, etc? *

Do you or loved ones feel as though they would be safer elsewhere? For example, assisted living, living with a care provider, skilled nursing facility, etc? *

Are you a former member of the armed services receiving care under the VA? *