Personal Family Caregiver Survey
The first step in the caregiver screening and assessment process is filling out a TCARE® Personal Family Caregiver Survey. The survey asks you to reflect on your experiences and is used to help you and the Family Caregiver Support Program better understand your situation to help locate the resources and support that meet your unique needs.  The survey takes about ten minutes to complete.

Please note: the grants that support this program ask that limited data be shared confidentially with our funders (Snohomish County Long-term Care & Aging and the City of Seattle).

This program through our Chapter is only available for unpaid family caregivers living in King & Snohomish counties who care for a person living in an independent setting. If you live outside of these counties or if your care receiver lives in long-term care, please contact our 24/7 Helpline for support and guidance: 800-272-3900
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Email *
Today's Date *
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Your First and Last Name *
Phone Number (e.g. 206-529-5500) *
Your Address (Street, City) *
Your Zip code: *
County of Residence *
Did your Health Care Provider encourage you to contact the Alzheimer's Association? *
If you are currently working with a Care Consultant at our Chapter, please share staff member's name:
1.  Are you the person most responsible for caring for an adult, such as your spouse, partner, parent, relative or friend, (care receiver)? Care receiver means any adult (18 years or older) who needs care or supervision by an unpaid caregiver. For example, a care receiver can be your spouse, partner, parent, adult child, friend, neighbor or other relative. *
1 a.  What is the First and Last name of the person receiving care? *
1b. Who do you care for? *
1c.  If you answered "other" in the previous question, please describe here. If not, skip this question.
2.  The following are thoughts and feelings people sometimes experience when they assist their care receiver. As you read through each of the following statements, to what extent do you agree or disagree with each statement? *
Strongly Disagree
Disagree
Disagree a little
Agree a little
Agree
Agree Strongly
a. I am not sure that I can accept any more responsibility than I have right now.
b. I am not always able to be the person I want to be when I am with my care receiver.
c. It is difficult for me to accept all the responsibility for my care receiver.
3. Which of the following best describes your care receiver’s memory? *
4. Given your care receiver’s CURRENT CONDITION, would you consider having them move to an out-of-home, long-term care setting? *
5. As a result of assisting the care receiver, have the following aspects of your life changed? *
Strongly Disagree
Disagree
Disagree a Little
Agree a Little
Agree
Strongly Agree
a. Your caregiving responsibilities have caused conflicts with your care receiver.
b. Your caregiving responsibilities have given your life more meaning.
c. Your caregiving responsibilities have increased the number of unreasonable requests made by your care receiver.
d. Your caregiving responsibilities have made you more satisfied with your relationship.
e. Your caregiving responsibilities have caused you to feel that your care receiver makes demands over and above what they need.
f. Your caregiving responsibilities have created a feeling of hopelessness.
g. Your caregiving responsibilities have given you a sense of fulfillment.
h. Your caregiving responsibilities have changed your routine.
i. Your caregiving responsibilities have caused you to worry.
j. Your caregiving responsibilities left you with almost no time to relax.
6. For each of the following statements below, tell us how often you have felt this way in the past week. *
Rarely or none of the time (less than 1 day)
Some or a little more of the time (1-2 days)
Occasionally or a moderate amount of time (3-4 days)
All of the time (5-7 days)
a. How often have you had trouble keeping your mind on what you were doing?
b. How often have you felt depressed?
c. How often have you felt hopeful about the future in the past week?
d. How often have you had restless sleep in the past week?
What is the best way to contact you? [Please write in your preferred phone # or email address.] *
If we leave a Voicemail message, may we identify ourselves as the Alzheimer's Association? *
Any other contact considerations that we should be aware of?
A copy of your responses will be emailed to the address you provided.
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