Caregiver Survey  -  Help us Make a Difference!!

If you are a caregiver, caring for your loved one over 60 or if you are over 60 or a grandparent or relative of grandchildren less than 18 years old; please take a few moments to answer the following five simple questions concerning your caregiving role. It will only take a minute, and the information you provide will aid us in finding out your needs and will be completely confidential. See our privacy statement.

1. Who do you care for? Please check the one that applies to you:

Spouse   Parent   Grandparent   Sibling
Friend   Other Relative   Grandchild   Other
(If other, please explain in the comments field below)

2. Do you work outside the home?    Yes   No

3. Do you live with your loved one?    Yes   No

If you answered no to question 3, then you are a long distance caregiver. Please check the one that applies to you.
Live out of state   Live within the same county (In-state)
Live in different county (In-state)   Other
(If other, please explain in the comments field below)

4. What types of online support groups would interest you? 

General Group   Caring for a Spouse   Caring for Parents
Caring for Grandchildren   Disease Specific (Alzheimer’s, stroke, etc.)

5. What topics are you interested in learning more about?

Caring for Yourself & Caregiver Stress   Depression
Medication Management   Legal & Financial Issues
Caregiver Services   Medical Problems
Problems in Behaviors & Moods   Adoption Issues
Grandparent Headed-Households

Optional - Let us make a difference!!

If you have questions or would like someone from The South Plains Family Caregiver Program to contact you, please enter your contact information here: 

Name:
Email:
Phone:

Enter any comments in the space provided below:

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