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Ideas & Support for Caregivers

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Pre-Call Questionnaire

Thank you for taking the time to fill out this form – I know these things can be a pain.

Our call will be more helpful for you if I know all these things ahead of time. We can spend our time working on how to make things better for you instead of going over all this information.

Thank you so much!! ❤ Lili

What state or country do you live in? *

What is your time zone? *

The person I am caring for is my... *

Parent
Spouse
Grandparent
Aunt/Uncle
Child
Friend
Client
Other

How long have you been a caregiver? *

Under a year
1-2 years
3 years or more

Are you currently working in addition to being a caregiver? *

Yes
No

If yes, how many hours per week?

Standard 9-5
Evenings
Weekends
Overnight

Is the person you are caring for living in: *

Your home
Their home
Assisted living
Nursing home
In a rehab
Recovering in a hospital

If you do not live with the person you are caring for how far away are they from your home (i.e., minutes, miles)?

Are you also juggling: *

A spouse
A spouse and kids
A relationship
A relationship and kids
Other

Do you volunteer in addition to everything else? *

Yes
No

If so where and how often? (hours per week or hours per month)?

I am feeling: *

Exhausted and out of control
Exhausted but coping
Coping okay
Doing great but looking for a better way

Regarding Support Most of the time I feel: *

I have great support from friends
I have great support from family
I have great support from friends and family
Not feeling much support
Feeling alone in my mission to care for my loved one

I am doing great at managing everything but need more help with: *

Caregiving
Work
Relationship
Organization
Prioritizing my family/kids

I am part of a: *

Church/religious organization
Veteran organization
Local support group
Other group
None of the above

My group is supportive:

Yes
No

If yes, is your group supportive and how do they support you?

My Biggest Concern / Problem is *

Hiring caregivers
Getting everything organized
How to create a better life for my loved one
How to navigate the healthcare system
How to get everyone to work together
How to help my loved one transition

My 2nd biggest concern is: *

Hiring caregivers
Getting everything organized
How to create a better life for my loved one
How to navigate the healthcare system
How to get everyone to work together
How to help my loved one transition

I am taking good care of myself: *

Yes
No
Sometimes

Do you feel that you eat enough? What are your meals like? *

How much sleep are you getting a night? *

Less than 4 hours
4-6
6-8
8 or more

Do you have time to yourself every day? *

Half-hour
1 hour
2 or more hours
Less than a half-hour

I prefer communication by: *

Text
Email
Phone
Other

Is there anything else you want me to know before we talk? *

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Email Address *

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If you need help now please call the mental health hotline at 988 or visit Center for Loss & Life Transition to find a counselor in your area.

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