TCARE Screening Questions
If you are an unpaid caregiver and would like to receive free services offered by Kin On's Family Caregivers Support Program, please fill out the following survey to let us know how we can serve you! A Kin On Social Worker will contact you within 5-7 business days once your form is submitted.
Today's Date
Your Name
Phone Number
Email Address
Mailing Address
Caregiver Birthday
Care Recipient Birthday
1. Are you the person most responsible for caring for an adult, such as your spouse, partner, parent, relative or friend, (care receiver*)?
* Care receiver means any adult (18 years or older) who needs care or supervision by an unpaid caregiver. For example, a care receiver can be your spouse, partner, parent, adult child, friend, neighbor or other relative.
Clear selection
2. Who do you care for?
3. INSTRUCTIONS: The following are thoughts and feelings people sometimes experience when caring for an adult. Read through each of the statements below and indicate how much you agree or disagree with each statement by making a check in the appropriate box.
Strongly Disagree
Disagree a Little
Agree a Little
Agree Strongly
a. The things I am responsible for do not fit very well with what I want to do.
b. I am not always able to be the person I want to be when I am with my care receiver.
c. It is difficult for me to accept all the responsibility for my care receiver.
d. I am having trouble accepting the way I relate to my care receiver.
e. I am not sure that I can accept any more responsibility than I have right now.
f. It is difficult for me to accept the responsibilities that I now have to assume.
Clear selection
4. INSTRUCTIONS: The following are aspects of life that can change as a result of caregiving responsibilities. Please check the box that best reflects how you feel about each of the following statements.
My Caregiving responsiblities have:
Not at all
A Little
A Lot
A Great Deal
a. Caused conflicts with my care receiver.
b. Decreased time I have to myself.
c. Created a feeling of hopelessness.
d. Given my life more meaning.
e. Increased the number of unreasonable requests made by my care receiver.
f. Kept me from recreational activities.
g. Made me nervous.
h. Made me more satisfied with my relationship with the care receiver.
i. Caused me to feel that my care receiver makes demands over and above what he/she needs.
j. Caused my social life to suffer.
k. Depressed me.
l. Given me a sense of fulfillment.
m. Made me feel I was being taken advantage of by my care receiver.
n. Changed my routine.
o. Made me anxious.
p. Left me feeling good.
q. Increased attempts by my care receiver to manipulate me.
r. Given me little time for friends and relatives.
s. Caused me to worry.
t. Made me enjoy being with my care receiver more.
u. Left me with almost no time to relax.
v. Made me cherish my time with my care receiver.
Clear selection
5. INSTRUCTIONS: Please indicate how often have you felt the following during the past week?
Rarely or none of the time (less than 1 day)
Some or a little of the time (1-2 days)
Occasionally or a moderate amount of time (3-4 days)
All of the time (5-7 days)
a. I was bothered by things that usually don’t bother me.
b. I had trouble keeping my mind on what I was doing.
c. I felt depressed.
d. I felt that everything I did was an effort.
e. I felt hopeful about the future.
f. I felt fearful.
g. My sleep was restless.
h. I was happy.
i. I felt lonely.
j. I could not “get going.”
Clear selection
6. Please indicate which of the following best describes your care receiver’s memory.
Clear selection
7. Given your care receiver’s CURRENT CONDITION, would you consider having him or her move to an out-of-home, long-term care setting?
Clear selection
Thank you for completing this survey!
A Kin On Social Worker will contact you within 5-7 business days once your form is submitted.
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