Home Who We Are Help for the Caregiver Caregiver Support for Companies FREE Two-Minute Caregiver Assessment Caregiver Wellness Assessment Registration Integrated Caregiver Pathway 50 State Nurse Aide Registry Nebraska Nurse Aide Registry Medicare Interactive Scholars and Practitioners Calendar Contact Us Connect with us on Facebook Caregiver Support Services are members of: Alzheimer’s Foundation of America National Family Caregivers Association (NFCA) Two-Minute Caregiver Assessment Please answer all questions below. After completion, your results will be calculated and displayed for you. * all survey fields are required Caregiver Information First Name:*  Last Name:*  E-mail Address:*  State:*  Working and Caregiving 1. Are you currently working full or part time in addition to caregiving? Full time Part time Not applicable 2. Caregiving takes time out of my workday? Yes Somewhat Not at all Medication Management 1. I assist my loved one with managing his/her medications. Yes Sometimes Not at all 2. I understand what my loved one's medications are for, their possible side effects, and how they may interact with one another. Yes Somewhat Not at all Depression 1. I have feelings of loneliness? Yes Sometimes Not at all 2. I wake up worrying about caregiving in the middle of the night. Yes Sometimes Not at all Smaller Tasks 1. I feel disorganized and could use assistance in organizing the care of my loved one. Yes Sometimes Not at all 2. When I ask for help from family and/or friends I generally receive the help. Yes Sometimes Not at all Stress 1. I have emotional or physical health problems? Yes Sometimes Not at all 2. Do you have frequent nights where you are not able to sleep through the night? Yes Sometimes Not at all Outsourcing 1. I am familiar with programs and/or services that may help me with caregiving? Yes Somewhat Not at all 2. I have a plan in place for the future care of my loved one. Yes Somewhat Not at all Preplanning 1. I have a plan in place in case there is a sudden loss of my loved one. Yes Somewhat Not at all 2. I know where to locate the necessary emergency paperwork in the case of an emergency. Yes Somewhat Not at all Music Controls  Return to Top    Who We Are   Help for the Caregiver   Caregiver Support for Companies   FREE Two-Minute Caregiver Assessment   Caregiver Wellness Assessment   Registration   Integrated Caregiver Pathway   50 State Nurse Aide Registry   Nebraska Nurse Aide Registry   Medicare Interactive   Scholars and Practitioners   Calendar   Contact Us Copyright © 2010 CaregiverSupportServices.org. All rights reserved Privacy Policy Website created by Terrence Green Website hosted by Web Solutions Omaha