SJC COA Caregiver Needs Assessment 2024

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Please complete this confidential survey so that we can best meet your needs.

Email *

First name *

Last Name *

Street Address *

City *

State *

Zip Code *

Phone number *

If you are a caregiver, please state the Name of person you are caring for (if you are the one experiencing memory loss please state "Self" :
*

Relationship of the person you are caring for

(Your care recipient Eg: Husband, wife, parent, etc.):

Have you or your care recipient been given a diagnosis? Please comment if you have any immediate needs to be addressed
*

All of these services are Free. Please mark the areas that best meet your needs:
*

Caregiver Support Group (Virtual on Zoom) 1st & 3rd Tuesdays of the month at: 12:30pm

Caregiver Support Group (Virtual on Zoom) 2nd and 4th Thursday of the month at: 1:00pm 2

In-person Caregiver Support Group in St. Augustine

In-person Caregiver Support Group in Ponte Vedra

In-person Caregiver Support Group in Nocatee

Caregiver Video classes "Guidance through the Car-Giving Journey"sent to your email (3 part series) The book on this topic "Guidance Through the Care-Giving Journey" is available on Amazon and Kindle

In person SAVVY Caregiver Classes (6 part series). (as available)

Private Caregiver Consult with a Certified Dementia Practitioner

Request for a phone call for specific question (s)

Information about Integrated Memory Enhancement Program (IMEP) for early stage dementia

Information about COA Adult Day Care Program

Information about other Community services available (Ex: Govt. Financial Assistance, V.A., Home Care, Assisted Living, Legal Aid etc),

Information about Meals-on-Wheels

I am interested in purchasing the book "Guidance Through the Care-Giving Journey" - "Into the World of Dementia" send me the link.

Required

I am currently receiving the following assistance:

(after completing this portion of the survey, including listing the assistance you are currently receiving below; please answer the next 12 confidential questions that will help us determine how the challenges of dementia care are affecting your life at this time. Answer these questions as honestly as possible, as you will be asked to complete a follow up survey in the next few months. This allows us to compare and see if any of the interventions you take part in are helpful to your caregiving experience. Your honest input is important to our research, as we aim to provide services aimed at assisting caregiver needs. Names and any identifying factors will remain confidential. Thank you for your assistance in this matter.

1. Do you feel that because of the time you spend with your care recipient that you don't have enough time for yourself?
*

0 Never

1 Rarely

2 Sometimes

3 quite Frequently

4 Nearly Always

2. Do you feel stressed between caring for your relative and trying to meet other responsibilities (work, family)?
*

0 Never

1 Rarely

2 Sometimes

3 quite Frequently

4 Nearly Always

Option 6

3. Do you feel angry when you are around your care recipient?
*

0 Never

1 Rarely

2 Sometimes

3 quite Frequently

4 Nearly Always

Option 6

4. Do you feel your care recipient currently affects your relationship with family members or friends in a negative way?
*

0 Never

1 Rarely

2 Sometimes

3 quite Frequently

4 Nearly Always

Option 6

5. Do you feel strained when you are around your care recipient?
*

0 Never

1 Rarely

2 Sometimes

3 quite Frequently

4 Nearly Always

Option 6

6. Do you feel your health has suffered because of your involvement with your care recipient?
*

0 Never

1 Rarely

2 Sometimes

3 quite Frequently

4 Nearly Always

Option 6

7. Do you feel that you don't have as much privacy as you would like because of your care recipient?
*

0 Never

1 Rarely

2 Sometimes

3 quite Frequently

4 Nearly Always

Option 6

8. Do you feel that your social life has suffered because you are caring for your care recipient?
*

0 Never

1 Rarely

2 Sometimes

3 quite Frequently

4 Nearly Always

Option 6

9. Do you feel you have lost control of your life since your care recipient's illness?
*

0 Never

1 Rarely

2 Sometimes

3 quite Frequently

4 Nearly Always

Option 6

10. Do you feel uncertain about what to do about your care recipient?
*

0 Never

1 Rarely

2 Sometimes

3 quite Frequently

4 Nearly Always

Option 6

11. Do you feel you should be doing more for your care recipient?
*

0 Never

1 Rarely

2 Sometimes

3 quite Frequently

4 Nearly Always

Option 6

12. Do you feel you could do a better job in caring for your care recipient?
*

0 Never

1 Rarely

2 Sometimes

3 quite Frequently

4 Nearly Always

Option 6

Thank you for completing this registration and confidential caregiver survey. Press the Submit button to send us this survey. You will be contacted by phone or email for information on how we may be able to assist with your requests and caregiver needs within the next few business days.

You can also reach us at 904-209-3674 .

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