You can always press Enter⏎ to continue
Free Workbook/Study Guide "How To Have Difficult Discussions With Your Aging Loved One."
Hi there, please fill out and submit this form to receive your download.
9
Questions
START
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.
Previous
Next
Submit
Press
Enter
2
Name
*
This field is required.
First Name
Last Name
Previous
Next
Submit
Press
Enter
3
Email
*
This field is required.
example@example.com
Previous
Next
Submit
Press
Enter
4
How long have you been a caregiver?
*
This field is required.
Previous
Next
Submit
Press
Enter
5
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.
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Previous
Next
Submit
Press
Enter
6
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.
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Previous
Next
Submit
Press
Enter
7
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.
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Previous
Next
Submit
Press
Enter
8
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.
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Previous
Next
Submit
Press
Enter
9
What is your biggest obstacle in letting go of caregiving?
*
This field is required.
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
9
See All
Go Back
Submit