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 help now

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

What is the current situation with your aging loved one?* This field is required.

5

What is becoming too much to handle?* This field is required.

6

Is your responsibility as a caregiver becoming unmanageable?* This field is required.

YESNO

7

On a scale from 1-10 how frustrated are you with the current situation?* This field is required.

8

Do your family members agree on the next steps of care?

YESNO

9

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

10

What is missing even though you are giving all you have?* This field is required.

11

Are you experiencing the first crisis with your loved one or is it one in a series?* This field is required.

12

Describe the current crisis.* This field is required.

13

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

14

If we decide working together is a good fit, do you financial resources to invest in planning for your aging loved one?

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.

15

Are you confused or overwhelmed by a new or existing diagnosis and need a "road map"?* This field is required.

YESNO