Caregiver Feedback
Provided by Wounded Warrior Project

First Name

Last Name

Email

ZIP Code

What stage of the journey describes your personal situation most accurately right now?
Becoming Aware and Adjusting (“I am still adjusting to the changes in the health of my loved one”)Shifting Priorities and Seeking Help (“I am having to make changes to my day to day life to pursue targeted assistance for my loved one”)Finding a Rhythm (“I may still encounter new challenges, but I feel like I have a handle on my caregiving responsibilities”)Other (Please describe)

How many friends/close relationships does your care recipient have in his/her life?
More than 5 close relationships4 to 5 close relationships2 to 3 close relationshipsOnly one close relationship with meNo close relationships

As a caregiver, how confident do you feel that you are trained to know when and how to provide support to your care recipient?
Very confidentMostly confidentSomewhat confidentMinimally confidentI am not confident that I can support or assist my warrior

What is your comfort level with your care recipient being with others without you there?
Very comfortableModerately comfortableSomewhat comfortableOnly comfortable with very few peopleNot comfortable at all

Do you and your family follow a consistent, regular routine?
We follow a consistent, regular routineWe have a plan for a routine but are inconsistent with following through with a routineWe have some ideas about establishing a routine but cannot get anything to workWe have no routine and do not know how to build oneWe do not think any routine will help

How much care/assistance does your care recipient need currently?
Self reliant; he/she does not need care, assistance or supervisionMinimal care and assistance; he/she can perform most life tasks on own and does not need supervisionPart-time care, assistance; he/she can perform many tasks on own and does not need supervisionPart-time care, assistance, supervision; he/she can perform some tasks on ownFull-time care, assistance and supervision at home by caregiverFull-time care, assistance and supervision by professionals

On average, approximately how many hours per week do you spend supporting your care recipient?
Less than 10 hours per week11 to 20 hours per week21 to 40 hours per week41 to 60 hours per weekMore than 60 hours per week

Do you feel as if you are participating in activities in your local community as much as you would like to (with or without your care recipient)?
Yes, as much as I would likeMost of the timeSomewhatNot that oftenNo, not at all

How much do you feel a part of your local community?
Very much soModerately soSomewhat soVery minimallyNot at all

How important is taking care of yourself and making time for your activities of interest?
Extremely importantVery importantModerately importantSlightly importantNot at all important

How often do you engage in an activity just for your own self-care?
5 or more times per week3 - 4 times per week1 - 2 times per weekA few times per monthNot at all

How satisfied are you with the frequency by which you are able to engage in an activity for your own self-care?
Completely satisfiedSomewhat satisfiedNeither satisfied nor dissatisfiedSomewhat dissatisfiedCompletely dissatisfied

Do you have any other feedback on the caregiver journey map that you would like to share with us?

Thank you for taking the time to fill out the feedback form for the digital Caregiver Experience Map. Your responses will help us form a more complete understanding of the caregiver journey, and make improvements to the map over time. We understand the importance of keeping your information private. The information you share will only be used in a summarized way. Personal information will not be shared. If you have any questions, please contact us at journey@caregiverjourney.elizabethdolefoundation.org.

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