Homework Form

1
Which Best Describes You?* This field is required.Select all that apply
I am an overwhelmed caregiver
I don't have time to figure out what to do next
I don't have the knowledge to know how to start the process of what next steps to take
I need consulting or coaching immediately because my loved one is in a crisis situation
I'm not sure what to do because I am lost in the process
2
Name* This field is required.
First Name
Last Name
3
Email* This field is required.
example@example.com
4
Is your loved one currently hospitalized or in sub-acute rehab and in the midst of a crisis?* This field is required.
YESNO
5
What is the current situation with your aging loved one?* This field is required.If your loved one is currently hospitalized or in sub-acute rehab, describe how I can help you now. If not, describe the current situation as it stands.
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Ok
6
What is becoming too much to handle?* This field is required.
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Ok
7
Is your responsibility as a caregiver becoming unmanageable?* This field is required.
YESNO
8
On a scale from 1-10 how frustrated are you with the current situation?* This field is required.
9
Do your family members agree on the next steps of care?* This field is required.
YESNO
10
Do you spend all your vacation time handling tasks for the one you care for? But, never seem to have enough time to give them the help they need?* This field is required.
YESNO
11
What is missing even though you are giving all you have?* This field is required.
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Ok
12
Are you experiencing the first crisis with your loved one or is it one in a series?* This field is required.
13
Describe the current crisis.* This field is required.If your loved one is currently hospitalized or in sub-acute rehab, be specific with the current situation. Otherwise, tell me what is happening right now that is causing the crisis.
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14
While the one you care for has a great doctor and the hospital staff is helpful, you never feel like you have a clear plan.* This field is required.
YESNO
15
If we decide working together is a good fit, do you financial resources to invest in planning for your aging loved one?* This field is required.
Yes, I have financial resources to invest and am ready to get help!
I have access to financial resources and am strongly considering getting help.
No, I do not have financial resources at this time and am not ready to get help.
I have financial resources or access to them, am ready to invest, and need consulting/coaching right now.
16
Are you confused or overwhelmed by a new or existing diagnosis and need a "road map"?* This field is required.
YESNO
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