Caregiver Survey

Email*
example@example.com

Do you experience the following as a caregiver?

	Yes, on a regular basis	Yes, sometimes	No, or rarely
My sleep is disturbed. (For example: The child I care for requires my assistance after bedtime and before 6 a.m.)
Caring for my child negatively impacts other aspects of my life. (For example: Personal relationships are negatively impacted because of the time I spend caring for my child.)
Caring for my child is a physical strain. (For example: Ambulatory care; child purposely or accidentally inflicts physical harm on parents.)
Caring for my child feels confining. (For example: Caring for my child restricts free time or social time beyond that of parents with typically developing children.)
Caring for my child requires significant family adjustments. (For example: Caring for my child disrupts my routine or changes individual responsibilities.)
Personal plans have to change to take care of my child. (For example: I had to turn down a job; I cannot keep plans.)
Other responsibilities have taken a back seat due to caring for my child. (For example: other family members needs or work)
There have been emotional adjustments. (For example: severe arguments about caregiving)
Some behavior is upsetting. (For example: The child I care for often has behavioral challenges.)
It's upsetting to me that my child's future is uncertain.
There have been work adjustments. (For example: I have to take time off for caregiving duties.)
Caring for my child creates financial strain.
I feel completely overwhelmed. (For example: I do not feel that I am caring for my child properly; I do not know the next step.)

Should be Empty: