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Caregiver Support Inquiry Form
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Email Address
*
How long have you been working in the role of caregiver?
*
Less than 6 months
6 months to 1 year
1 to 3 years
More than 3 years
How challenging do you consider your role as a caregiver?
Easy
Somewhat Easy
Neutral
Difficult
Very Difficult
What are the main sources of stress or burnout that you experience as caregiver? Select all options that apply:
Emotional Overload
Physical Overload
Lack of Time for Yourself
Difficulties in Communicating with the Patient
Feeling of Social Isolation
Guilty Feeling
Financial Difficulties
None of the Above
Other
If Other, please specify:
Have you ever felt like throwing in the towel as a caregiver?
Always
Frequently
Sometimes
Rarely
Never
Do you think you are alone and without help?
Yes
No
Sometimes
Have you sought emotional support or counseling to deal with your emotions and the stress associated with being a caregiver?
Yes, I am currently receiving help
Yes, but not on a regular basis
No, but I would like support or advice
I don't think I need support
What activities or strategies do you use to take care of your own well-being and reduce stress? (Select all that apply)
Practice Regular Physical Exercise
Quality Time with Friends and/or Family
Meditation or Relaxation Techniques
Seek Support from Caregiver Groups
Hobbies or Recreational Activities
Other
If Other, please specify:
Would you like to learn about additional resources or services that could help you ease the burden as a caregiver and prevent burnout?
*
Yes
No
Sometimes
Additional comments:
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