Caregiver Resources Treatment Selection Survey
Help us improve treatment resources by sharing your experiences and preferences as a caregiver.
Your Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number (optional)
Please enter a valid phone number.
Format: (000) 000-0000.
What is your relationship to the care recipient?
*
Parent
Spouse/Partner
Sibling
Friend
Professional Caregiver
Other
What type of condition or need are you supporting?
*
Please Select
Dementia/Alzheimer's
Physical Disability
Chronic Illness
Mental Health
Developmental Disability
Other
How satisfied are you with the current treatment resources available to you and the care recipient?
*
1
2
3
4
5
Please rate your agreement with the following statements about the resources and treatments available to you.
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I am aware of all treatment options available.
1
2
3
4
5
I feel supported by healthcare professionals.
6
7
8
9
10
Resources are easy to access.
11
12
13
14
15
Treatment options meet our needs.
16
17
18
19
20
Which treatment options have you used or considered for the care recipient? (Select all that apply)
*
Medication
Therapy/Counseling
In-home care services
Support groups
Alternative therapies
Other
What barriers have you faced in accessing treatment resources? (Select all that apply)
*
Cost
Lack of information
Transportation issues
Limited availability
Cultural or language barriers
Other
What additional resources or support would be most helpful to you as a caregiver?
Please share any suggestions or comments you have about improving treatment resources for caregivers.
Submit Survey
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