Doses of Sunshine, LLC
Caregiver Evaluation Form
Name (optional)
First Name
Last Name
Gender
Please Select
Female
Male
Prefer not to say
Age
Please Select
Less than 18
18-24
25-34
35-44
45-54
55-65
More than 65
Which best describes your relationship with the patient?
Spouse/Domestic Partner
Child
Relative
Other
1. Do you struggle with caring for your loved one?
Yes
No
2. Are you unsure what to do next in your loved one’s care?
Yes
No
3. Do you feel as though you have the necessary resources (i.e. time, money and/or support) to care for your loved one?
Yes
No
4. Do you struggle to communicate with family about care responsibilities?
Yes
No
5. Do you often feel invisible or misunderstood by friends or family?
Yes
No
6. Are you managing care while also working, parenting, or supporting others
Yes
No
7. Have you delayed important decisions because you feel emotionally exhausted?
Yes
No
8. Are you carrying emotions (grief, resentment, anxiety) that you haven’t had space to process/express?
Yes
No
9. Do you feel like you’ve lost touch with who you are outside of caregiving?
Yes
No
10. Do you feel guilty taking time for yourself?
Yes
No
Additional Comments and Notes
If you answered yes to three or more of the questions, please reach out to see how we can help.
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