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Caregiver Assessment 
Caregiver Assessment helps Age Friendly Cold Lake understand the needs, challenges, and strengths of caregivers to provide better support and resources.  
Email *
Date: *
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Caregiver’s First Name:

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Caregiver’s Last Name *
Caregiver’s Phone Number *
Care Recipient’s First Name: *
Care Recipient’s Last Name: *

Caregiver’s Relationship to Care Recipient:

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Required
Diagnosis Received
Type of Dementia *
Stage of Dementia   *
Required
CAREGIVER DEMOGRAPHICS and LIVING ARRANGEMENT
Marital Status *
Required
Race *
Required
CAREGIVER NEEDS

Were you aware of the caregiver support resources prior to making this contact?

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Required

If Yes, have you received caregiver support services in the past?

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Required

If No, what prompted you to seek help now?

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Do you have concerns about receiving caregiver support? (Check all that apply.)

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Required

Other; please describe:

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CAREGIVER PROFILE
Are you paid to provide care? *
Required
Are you the only non-paid person providing care? *
Required
How long have you been providing care for the care recipient ? *
Required

How often do you provide care to your care recipient ?

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Required

Do you have children under the age of 18?

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Required

Are you also providing care to any other individuals?

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Required

Is there anyone you can call on in an emergency to fill in for you as a caregiver?

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Required

Distance to care recipient's home

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Required

Do you have a chronic health condition or have you experienced a recent health crisis?

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Required

Caregiver’s health condition/crisis:

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Has this health condition affected your ability to care for the care recipient?  

Are you employed?

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Required

Have your caregiver responsibilities ever affected your employment?

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Required
How has your employment been affected? 

Schedule

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Required

Pay

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Required

Leave

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Required

Work Relationships

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Required

Performance

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Required
CAREGIVER SKILLS and TRAINING ASSESSMENT 

Which of the following tasks do you assist your recipient with? (Check all that apply.)

Other: Please describe

If  your care recipient  has a chronic disease or condition, how knowledgeable do you feel about this disease or condition?

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Required
Do you need information, education and/or training about the following? (Check all that apply.

Other: Please describe

CAREGIVER STRESS INTERVIEW

Do you find caring for the care recipient to be stressful?  

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Required

Would you rate your stress level as:

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Required
CHECK THE RESPONSE THAT BEST DESCRIBES HOW YOU FEEL 
I feel a sense of satisfaction helping the care recipient *
Required
I am confident about providing care to the care recipient *
Required

Caring for my care recipient while trying to meet other responsibilities (such as family or work) is causing increased stress

*
Required

I feel a sense of obligation to provide care

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Required

My health has suffered because of my involvement with providing care

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Required

My finances are strained because I provide care

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Required

I could do a better job of caring for the care recipient

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Required

What do you do to cope with the stress related to the challenges of caregiving? Describe:

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Is this working to help relieve stress?

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Required
CAREGIVER PRIORITY STATUS *
Required
Optional Targeting Categories
 *
Required
NOTES *
Homecare Case Manager/Social Worker Name:
 *
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