Stress Busters Program Eligibility
Thank you for your interest in the Stress Busters program!  Because we want to make sure that the program is a good fit for you, and because we keep our groups small (8-10 participants), we pre-screen all potential participants.  (You may also call Chris at 847-596-8226 if you prefer.)  
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1. Your first name? *
2. Do you or the person you care for live in one of the following Illinois counties?   DuPage, Grundy, Kane, Kankakee, Kendall, Lake, McHenry, Will *
3. Please provide your PHONE NUMBER and EMAIL ADDRESS so we can contact you with official registration information and/or questions.  WE DO NOT SHARE THIS INFORMATION. *
4. Does the person you are caring for have Alzheimer's disease, other dementia, or other form of memory loss? *
5. What is your relationship to the person you are caring for?  (Spouse, adult child, sibling, friend, etc.) *
6. About how much time do you spend on caregiving responsibilities each week?  (Include hands-on care, helping, planning, etc.) *
7.  Are you willing to commit to attending the 10 program sessions ?  (NOTE:  Participants are allowed to miss up to 3 sessions.) *
8.  Do you need someone to stay with the person you are caring for while you attend the program? *
9.  Is there anyone else in your family who would like to attend the program with you? *
10.  What do you hope to gain from the program? *
Thank you for completing this survey.  We will contact you withing the next 24 hours to verify your interest in the program.  If you have questions, please contact Chris at 847-596-8226.
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