Powerful Tools for Caregivers Screening Tool

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Thank you for your interest in the Powerful Tools for Caregivers we are offering at SWIRCA. Powerful Tools for Caregivers is an educational series designed to provide you with the tools you need to care for yourself.

Please answer the following questions, and after review, a member of the Powerful Tools for Caregivers team will contact you to further discuss and see if this education series would be beneficial to you at this time.

Name *

E-mail address *

Address (Please include, street, city and state) *

Phone Number *

Preferred Method of Contact *

Phone

Other:

Time Preference for class

Morning

Afternoon

Evening

Clear selection

Class preference

In Person

Virtual

No Preference

Clear selection

Do you have reliable internet connection? *

Yes

If not, do you/are you willing to find somewhere that does during the class time?

Do you have a computer or smart phone that you would be willing to use for video and audio through Zoom for the class? *

Yes

Are you currently a caregiver? *

Yes

If so, what is your relationship to individual you are caring for? How long? *

Are you be able to devote an hour and a half of uninterrupted time to attend the class once a week for 6 weeks? *

Yes

Maybe

Are you able to pay $30 for the caregiver handbook if needed? *

Yes

How did you hear about the Powerful Tools for Caregivers classes? *

Submit

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