Caregiver Assessment Survey
SJC COA Caregiver Needs Assessment 2023
Please complete the following information. This information will be used to better serve you.
There are 29 questions in this survey.

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Caregiver Information

Select Today's Date:*
What is your email address?*
Re-type your email address:*
What is your First Name?*
What is your Last Name?*
What is your Street Address?*
What City do you live in?*
What State do you live in?*
What is your Zip Code?*
What is your Phone Number?*
If you are a caregiver, please state the Name of person you are caring for (if you are the one experiencing memory loss please state "Self" :*
Relationship of the person you are caring forĀ  (Your care recipient Eg: Husband, wife, parent, etc.):*
Have you or your care recipient been given a diagnosis? Please comment if you have any immediate needs to be addressed:*
All of these services are Free. Please mark the areas that best meet your needs:*
I am currently receiving the following assistance: (after completing this portion of the survey, including listing the assistance you are currently receiving below; please answer the next 12 confidential questions that will help us determine how the challenges of dementia care are affecting your life at this time.*
Please take a moment to complete these final personal caregiving questions as honestly as possible. Your information will remain confidential and will be used to help us to better understand and serve your individual needs.
1. Do you feel that because of the time you spend with your care recipient that you don't have enough time for yourself?*
2. Do you feel stressed between caring for your relative and trying to meet other responsibilities (work, family)?*
3. Do you feel angry when you are around your care recipient?*
4. Do you feel your care recipient currently affects your relationship with family members or friends in a negative way?*
5. Do you feel strained when you are around your care recipient?*
6. Do you feel your health has suffered because of your involvement with your care recipient?*
7. Do you feel that you don't have as much privacy as you would like because of your care recipient?*
8. Do you feel that your social life has suffered because you are caring for your care recipient?*
9. Do you feel you have lost control of your life since your care recipient's illness?*
10. Do you feel uncertain about what to do about your care recipient?*
11. Do you feel you should be doing more for your care recipient?*
12. Do you feel you could do a better job in caring for your care recipient?*
Thank you for completing this registration and confidential caregiver survey. Press the Submit button to send us this survey.*
Prev Submit NOTE: There might be a slight delay in loading the next screen after clicking the SUBMIT button. Please be patient. Thanks.