Caregiver Survey

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.

Caregiver Survey – Help us Make a Difference!

1. Who do you care for? Please check the one that applies to you: 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? 2. Do you work outside the home? Yes No

3. Do you live with your loved one? 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. 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? 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? 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

Comments

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 Address

Phone

Comments

Caregiver Survey

Help us make a difference! Please take a few moments to answer the 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.

Take the Survey

Helping Caregivers

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