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.
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    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.
    Please enter one response per row
    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.
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    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.”
    Please enter one response per row
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    Thank you for completing this survey!

    A Kin On Social Worker will contact you within 5-7 business days once your form is submitted.