A new, local nonprofit is getting ready to launch free respite care for caregivers at no cost.  This survey is for unpaid caregivers only, and will help determine the level of need for these services.  If you are an unpaid caregiver, please take time to fill out this survey and all information will be kept confidential.  Please complete survey only one time  Thank you for your valuable input.

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* 1. Are you a unpaid caregiver caring for a loved one at home?

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* 2. What is your gender?

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* 3. Who are you caring for?

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* 4. Enter the age of the person you are caring for?

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* 5. Please describe their disability, illness or need for caregiving.

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* 6. How many hours per week do you spend on caregiving? Please describe a typical week.

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* 7. As a caregiver what are your biggest challenges and needs?

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* 8. As a caregiver, how do you view your own health?

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* 9. Would you utilize a cost free respite service for caregivers if your community had this available to you?

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* 10. Would you like to learn more about this cost free service?

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