Dementia Friendly - Caregiver Services & Supports
Survey for family and professional caregivers.

Services and supports for family caregivers of people with dementia are needed in communities striving to become dementia friendly. They include counseling, support groups, caregiver coaching, care consultation, respite, and education and training on dementia and care needs.   
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Name *
Type of caregiver *
If "Other" above, please explain.
Zip Code *
Phone
Email *
Have you had personal experience with someone with dementia?
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Have you had professional experience with someone with dementia?
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What do you see as our community's main strengths for addressing the needs of people living with dementia and their families?    
What do you see as our community's main gaps for addressing the needs of people living with dementia and their families?    
What resources and organizations would you suggest to individuals who may show signs of dementia?
Indicate your level of agreement with this statement: Our community currently has adequate awareness of the resources and organizations available to support people with dementia and their families.
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Indicate your level of agreement with this statement: Raising community awareness of the resources and organizations that can help support people with dementia and their families should be a priority for action in out community.
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Indicate your level of knowledge of the 10 warnings signs of dementia
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Indicate your level of agreement with this statement: Increasing our community members' knowledge about warning sings of dementia should be a priority for action in our community.
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Indicate your level of agreement with this statement: I have good skills for interacting with people with dementia.
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Indicate your level of agreement with this statement: Increasing our community members' skills for interacting with people with dementia should be a priority for action in our community.
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Indicate your level of agreement with this statement: Our community currently has adequate dementia-related resources tailored to our diverse and underserved populations.
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Indicate your level of agreement with this statement: Increasing dementia-related resources tailored to our diverse and underserved populations should be a priority for action in our community.
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For professional caregivers of people with dementia, do you currently provide education and training about Alzheimer's disease and care needs?
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If yes, list the trainings and briefly describe each (title, content).
Indicate your level of agreement with this statement: Caregivers of people with dementia in our community currently receive adequate education and training on dementia.
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Indicate your level of agreement with this statement: Increased education and training on dementia for caregivers of people with dementia should be priority for action in our community.
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Do you currently offer family counseling/family meetings for caregivers of people with dementia?
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Do you currently offer support groups for caregivers of people with dementia?
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Do you currently offer mentoring programs/peer support for caregivers of people with dementia?
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If you offer other counseling/support services for caregivers of people with dementia, please describe what you offer.
Do you currently offer adult day programs?
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Do you currently offer emergency or crisis respite?
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Do you currently offer extended respite?
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Do you currently offer in-home respite?
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Do you currently offer overnight or weekend respite?
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If you offer respite in some capacity, is your respite service tailored to dementia? (if so, how?)
If you offer respite in some capacity, are your respite options social in nature only or do they include medical care as well?
Indicate your level of agreement with this statement: Our community has an adequate level of respite programs or services for caregiver of people with dementia.
Clear selection
Indicate your level of agreement with this statement: Increasing the level of respite programs or services for caregivers of people with dementia should be a priority for action in our community.
Clear selection
Indicate your level of agreement with this statement: Our community has an adequate level of counseling/support groups for caregivers of people with dementia.
Clear selection
Indicate your level of agreement with this statement: Increasing the level of counseling/support groups for caregivers of people with dementia should be a priority for action in our community.
Clear selection
Do you offer caregiver coaching (specifically for caregivers of people with dementia)?
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Do you offer care consultation (specifically for caregivers of people with dementia)?
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Do you offer any other services for caregivers (specifically for caregivers of people with dementia)?
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If yes, what services do you offer?
Indicate your level of agreement with this statement: Our community provides an adequate level of caregiving coaching/care consultation services for caregivers of people with dementia.
Clear selection
Indicate your level of agreement with this statement: Increasing the level of caregiving coaching/care consultation services for caregivers of people with dementia should be a priority for action in our community.
Clear selection
Would you be interested in helping us create a dementia-friendly community?
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What other organizations/groups in our community should take part in creating a dementia-friendly community?
Can we stay in touch with you to let you know how the project is progressing and how you can help to ensure our community is becoming dementia friendly?
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Please share any additional thoughts and/or feedback that might help us provide appropriate resources in our area for those with dementia and their care partners.
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