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Caregiver Support Assessment

Please take a few minutes to complete this assessment so we can better understand how to support you.

Your responses will help us shape the products, services, and resources we offer to caregivers like you.

This assessment is for you. There are no right or wrong answers. We simply want to understand your experience and find meaningful ways to give back and say thank you.

We see you. We appreciate you. We are here to support you.

All questions are based on how you have felt over the past six months.

Sign in to Google to save your progress. Learn more
Email *
Name: *
Address: *
Phone Number: *
Birthday: *
1. I have had trouble keeping my mind on what I was doing *
2. I have felt I couldn't leave my loved one/client alone *
3. I have had difficulty making decisions *
4. I have felt completely overwhelmed *
5. I have felt useful and needed *
6. I have felt lonely *
7. I have felt a loss of privacy and/or personal time *
8. I have been edgy or irritable *
9. I have had sleep disturbed because of caring for my loved one/client *
10. I have had a crying spell(s) *
11. I have felt strained between work and family responsibilities *
12. I have had back pain *
13. I have felt ill (headaches, stomach problems, etc...) *
14. I have been satisfied with the support my family/employer has given me *
15. I find my loved one/client's living situation to be inconvenient or a barrier to care *
16. On a scale from 1 to 5, rate your current level of stress... 1 no stress, 5 stressed out! *
17. On a scale of 1 to 5, please rate your current health compared to what it was this time last year... 1 well and about the same, 5 worse and please help! *
18. What are some of your favorite hobbies? *
19. What makes you happy? *
20. Are you a Caregiver at a Facility or Home or Both? *
21. What are some of your favorite things: food, treats, color, movies, books etc... *
22. What are the 1-3 top things that would help support you best on your Caregiving Journey?  (Examples: emotional support, practical help, rest, community, education, financial relief, time for yourself or anything else. Or simply write “I don’t know.” ) *
Anything else you'd like to share?
ALL information is kept strictly confidential with The Caregiving Corner! Thank you!  I look forward to connecting! :)
Reach Out:
If you haven't already, please join the private caregiver support group: https://www.facebook.com/groups/thecaregivingcornersupportgroup 
Any addition questions, please send an email to: thecaregivingcorner@gmail.com

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