Caregiver Overwhelm, Stress, & Burnout Questionnaire

1
Which of the following best describes you?* This field is required.
I am an overwhelmed caregiver.
I don't have time or knowledge to figure out what to do next with my loved one.
I need help now.
I can relate to all of the options.
2
Name* This field is required.
First Name
Last Name
3
Email* This field is required.
example@example.com
4
How long have you been a caregiver?* This field is required.
5
Briefly describe your caregiver responsibilities.* This field is required.
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Ok
6
What's your loved one's current diagnosis?* This field is required.
Dementia
Diabetes
Obesity
CHF
Cancer
Frailty
Other
7
How obligated do you feel in taking care of your loved one?Follow the emoji's facial expression. Sliding the emoji to the left is worse than sliding to the right.
8
Where do you fall on the overwhelm scale?* This field is required.Follow the emoji's facial expression. Sliding the emoji to the left is worse than sliding to the right.
9
How much stress do you have because of being a caregiver?* This field is required.Follow the emoji's facial expression. Sliding the emoji to the left is worse than sliding to the right.
10
How much burn out are you currently feeling?* This field is required.Follow the emoji's facial expression. Sliding the emoji to the left is worse than sliding to the right.
11
Which symptoms are you currently feeling?* This field is required.
Anger
Fatigue
Depression
Impaired Sleep
Poor Health
Irritability
A terrible sense there's no way out
Lost interest in activities you use to enjoy
Headaches or other physical pain
Losing or gaining weight
Anxiety
Other
12
Could you let go of your caregiver obligation and expectations?* This field is required.
YESNO
13
What is your biggest obstacle in letting go of caregiving?* This field is required.
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14
What relief could you find if you ended caregiving?* This field is required.
15
Have you ever talked to the one you care for about your struggles?* This field is required.
YESNO
16
Have you ever talked to a professional to help relieve your caregiver overwhelm, stress, or burnout?* This field is required.
YESNO
17
How willing and able are you to talk to someone and invest about a care plan change for your loved one?* This field is required.
I'm ready right now and have resources to schedule a call
I'm strongly considering it and have access to resources to schedule a call
Maybe in the future when things get worse and have I access to resources
Not ready yet and don't have financial resources to invest
18
If we decide together it's time to work with Midwest Geriatric Consulting Services, LLC, how soon could you get started?* This field is required.
19
Please provide any additional information that you feel is important.
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