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Coffee For Caregivers Interest Form
Just a few quick questions to help me form new groups. Thank you!
* Indicates required question
Email
*
Your email
Your name (first and last)
*
Your answer
What is your time zone?
*
Your answer
What time block is best for you? (Note: times below are Pacific Time)
*
Tuesdays 9am - 11am Pacific Time
Tuesdays 2pm - 4pm Pacific Time
Wednesdays 7am - 8am Pacific Time
Wednesday 10am - 11am Pacific Time
Are you in the Sandwich Generation - children in your home and caregiving for an aging loved one?
*
Yes
No
Other:
If you have children, what are their ages?
Your answer
Who are you giving care to?
*
Your answer
What are the needs of the person you're caring for?
*
Dementia (Includes Alzheimer's, Lewy Bodies Dementia, Vascular Dementia, etc.)
Mild Cognitive Impairment associated with another condition
Stroke
Heart Condition
Other:
Required
Have you been part of a support group before?
*
Yes
No
Other:
If you have been in a support group or self-help group before, How did you feel about the experience?
Your answer
What are your hopes (expectations) for the group?
*
Your answer
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