Name
(Optional) |
| Date of Birth
|
|
| Gender:
Male /
Female |
|
| |
|
| Address
|
| Town
State
Zip
|
| Home Phone
|
Work Phone
|
| |
|
| Relationship to the Person You Care
For: |
Spouse/Partner
Son/Daughter
Other relative, specify
Son-in-law/Daughter in Law
Non-relative
Informal Care Giver
|
| How long have you been a
care giver to this individual? |
Less than 6 months
6 -12 months
14 - 24 months
2 - 5 years
More than 5 years
|
|
| Does the person you care for live in
your home? |
Yes
No
|
|
| Care Giver Information (check all that
apply): |
Has own medical problems
Has children
Works full-time
Works part-time
Retired, but works part-time
Decreased work hours because of caregiving tasks
Gave up job to care for client
Is fully retired
Is a homemaker
Is unemployed
Other, please specify
|
| What types of care do you provide? |
|
Companionship
Personal Care (bathing, dressing, etc.)
Shopping Assistance
Housekeeping
Other,
|
| What types of support do you, as the
care giver, have? |
Other family members assist
Support group
Grant
No support system
|
| What other services, if any, does the
person you care for receive that helps ease your care
giving? |
Adult Day Care
Respite Care
Other, please specify
|
| On a scale of 1-5, how difficult is
it to manage your care giving responsibilities? |
1, not difficult
2, somewhat difficult
3, difficult
4, very difficult
5, extremely difficult
|
|
| What kind of help might make it easier?
|
| Client Name:
|
|
Thank you!
|
|
