Your Care Story

1
What Led You to Caregiving?* This field is required.People become caregivers for many reasons. Tell us what influenced your decision by selecting all that apply. Please check all the reasons that are true for you.
It’s my duty.
Professional care was too expensive.
I care because of my love, affection, and strong emotional ties to my loved one.
Caring for them makes me feel happy.
My loved one would not want anyone else to care for them.
It aligns with my religious belief.
It reflects my cultural values.
I had no other choice.
I became a caregiver unexpectedly, more by chance than by choice.
It provides financial benefits for me or my loved one.,
I feel personally responsible for my loved one as a family member.
2
Why Does Your Loved One Need Care?* This field is required.What are the main reasons your loved one needs care and support?
3
Your Biggest Challenge?* This field is required.What do you find most difficult about caring for your loved one?
4
What is your home zip code?* This field is required.We ask for your zip code to help connect you with relevant resources and support in your local community. Your information will only be used to improve the services available to caregivers like you.
5
Your Relationship Matters* This field is required.Who is your loved one to you? They are your…
Spouse or Partner
Daughter or Son (in-law, step), Grandchild, Foster Child
Parent or Grandparent (in-law, step)
Older Relative (aunt, uncle, godparent)
Sibling, Cousin, Niece or Nephew
Neighbor, Friend, or Colleague
Other
6
Understanding Their Care Needs* This field is required.Please select all the reasons your loved one needs care and support.
General concerns due to aging (e.g., increased frailty, reduced stamina, cognitive changes)
Short-term physical conditions (e.g., recovery from surgery, broken bones, temporary illness)
Mobility issues (e.g., arthritis, muscle weakness, balance issues)
Sensory impairments (e.g., vision loss, hearing difficulties, tinnitus)
Memory difficulties (e.g., forgetfulness, difficulty retaining new information)
Chronic health conditions (e.g., heart disease, stroke, diabetes, kidney disease)
Respiratory conditions (e.g., emphysema, COPD, chronic bronchitis, asthma)
Cancer (e.g., active treatment, remission, palliative care needs)
Long-term neurological conditions (e.g., ALS, Parkinson’s, Alzheimer's, Multiple Sclerosis, epilepsy)
Mental and emotional health conditions (e.g., depression, anxiety, PTSD, bipolar disorder, schizophrenia)
Substance use challenges (e.g., alcohol use disorder, opioid dependence, recovery support)
Behavioral challenges (e.g., aggression, impulsivity, difficulty with social interactions)
Intellectual or developmental disabilities (e.g., Down Syndrome, autism, cerebral palsy)
Infectious diseases (e.g., HIV/AIDS, hepatitis, long-term effects of infections like COVID-19)
Other
7
When is your loved one's birthday?* This field is required.
Date
Month
Day
Year
8
Tell Us About Yourself* This field is required.What is your race? Please select all that apply and provide details where requested. Pick all that apply
American Indian or Alaskan Native
Asian
Black or African American
Hispanic, Latino, or Spanish origin
Middle Eastern or North African
Native Hawaiian or Pacific Islander
White
Some other race or origin
9
Print, name of enrolled or principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, etc.
10
Print, for example, Chinese, Asian Indian, Filipino, Vietnamese, Korean, and Japanese, another group (for example, Pakistani, Hmong, Afghan etc.)
11
Print, for example, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, another group (for example, Trinidadian and Tobagonian, Ghanian, Congolese, etc.)
12
Print, for example, Mexican or Mexican American, Puerto Rican, Salvadoran, Cuban, Dominican, Guatemalan, another group (for example, Colombian, Honduran, Spaniard, etc.)
13
Print, for example, Lebanese, Iranian, Egyptian, Syrian, Iraqi, Israeli, another group (for example, Moroccan, Yemeni, Kurdish, etc.)
14
Print, for example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese, another group (for example, Chuukese, Palauan, Tahitian, etc.)
15
Print, for example, English, German, Irish, Italian, Polish, Scottish, another group (for example, French, Swedish, Norwegian, etc.)
16
Print race origin
17
Stay Connected and Get Your Results* This field is required.Your caregiving style reflects the unique motivations and circumstances that shape your role. You’ll see your results on the next screen. We will also email them to you along with helpful resources to support your journey.
First Name
Last Name
18
Get your results. Your email* This field is required.
example@example.com
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