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The privacy of our neighbors is important to us. TCI expects that you have received consent to share this information. Please confirm that you have attended to all necessary steps to make this request.

What town or municipality do you live in?

What town or municipality do you live in?

What pronouns do you use?

This allows TCI to effectively reach out to you. If you select "Text Message" as your Preferred Contact Method you agree to receive support messages from The Connection Initiative. Data/SMS rates may apply. To opt-out of messages, reply STOP at anytime.

What town or municipality does the person live in?

What town or municipality does the person live in?

What pronouns does the person use?

This allows us to reach you.

What is the age range of the person looking for a resource?

Please provide a brief description of your need.

In what timeframe do you need this connection?

How did you learn about The Connection Initiative?

What type of fuel do you use?

Please list the ages of the people in your household.

How much financial support do you need?

Please tell us about any relevant dietary requirements.

This will help us make a more efficient connection.

Your privacy is important to us. Please check this box if you consent to us sharing your information with our Resource Partners.

Please list any individual or organization with whom you would prefer we not share details of your request.

By making this request, you are agreeing to the terms of use and privacy policies of The Connection Initiative. Review these policies here: https://www.connectioninitiative.org/privacy

The Connection Initiative is working to connect adults who are 55 and older to resources and trusted community support to improve health and well-being. Would you like to participate in D-PHI? Participation is free. For more information about the Downeast Population Health Initiative, visit: https://connectioninitiative.org/d-phi

What number (0-10) best describes how much distress you have been experiencing in the last week?

How often do you feel lonely or isolated from those around you?

Rate the following statement from Strongly Disagree (1) to Strongly Agree (5): “I have people in my community who I can trust when I need help.”

Accessing or navigating primary care, scheduling appointments, or feeling heard and understood by healthcare providers. “Let’s talk about your experiences with primary care. Many older adults in this area face challenges like long waits or feeling like their provider doesn’t fully understand their needs. Let me know if any of these feel relevant to you.”

Select challenges related to primary care (select all that apply, yes/no):

Addressing barriers to cancer treatment, emotional support, or navigating survivorship needs. “Cancer care can be overwhelming. I’m going to ask a few questions to understand how your diagnosis, treatment, or follow-up care may be affecting you. Let me know which of these apply to you so we can prioritize where you need support.”

Select challenges related to cancer care (select all that apply, yes/no):

Concerns about memory, mobility, or creating a safe home environment. “Let’s explore how you’re managing your independence and safety. Some people worry about memory, mobility, or even their home setup. Let me know if any of these challenges apply to you so we can address them together.”

Concerns about memory, mobility, or creating a safe home environment.

Difficulty affording healthcare, transportation, or accessing essential resources like food or medical supplies. “Financial challenges often make it hard to focus on other areas of life. I’ll ask a few yes-or-no questions to understand where costs or resources might be barriers for you.”

Difficulty affording healthcare, transportation, or accessing essential resources like food or medical supplies.

Struggles with caregiving responsibilities or accessing help for personal care or daily tasks. “Caregiving or needing help yourself can be exhausting. I’m going to ask some questions about how you’re managing, and you can let me know if any of these apply to your situation.”

Struggles with caregiving responsibilities or accessing help for personal care or daily tasks.

Feeling isolated, disconnected, or lacking access to meaningful relationships or community activities. “Feeling connected to a community is important for well-being. I’ll ask some yes-or-no questions about how you feel in your community and what might make those connections stronger.”

Feeling isolated, disconnected, or lacking access to meaningful relationships or community activities.

Which of the following (if any) would you say is your biggest challenge right now?

What number (0-10) best describes how much distress you have been experiencing in the last week?

Rate the following statement from Strongly Disagree (1) to Strongly Agree (5): “I have people in my community who I can trust when I need help.”

How often do you feel lonely or isolated from those around you?

Add file or drop files here
    Subjective Units of Distress Scale:
    A Self-Assessment Tool
    10
    Unbearably upset. Can not function.
    9
    Extremely distressed.
    8
    Very distressed. Trouble focusing.
    7
    Quite distressed. Discomfort interfering with functioning.
    6
    Moderate to strong stress.
    5
    Moderate distress. Uncomfortable but still functional.
    4
    Mild to moderate distress.
    3
    Mild distress but able to function.
    2
    Slightly distressed, sad, or anxious.
    1
    No distress. Alert. Concentrating.
    0
    Peace. No distress. Complete calm.