Getting a Break

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* 1. On a scale from 1 to 5, with 1 being the least stressed and 5 being the most stressed, how stressed are you?

	1 Least Stressed	2	3	4	5 Most stressed
How stressed are you?	How stressed are you? 1 Least Stressed	How stressed are you? 2	How stressed are you? 3	How stressed are you? 4	How stressed are you? 5 Most stressed

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* 2. What's the cause of your stress? Check as many as appropriate.

A family member recently received a diagnosis

I am really lonely

I can't afford to hire enough help

I don't have enough help

I don't have enough money

I don't have enough time

I don't have enough time for other family members

I don't sleep well at night

I feel lost

I haven't had a break

I miss my life

I'm battling the health care bureaucracy

I'm facing a difficult decision

I'm fighting the insurance company red tape

I'm not confident in what I'm doing

I'm trying to keep my job

My caree has died

My caree is dying

My caree's care needs are overwhelming

My caree's health is declining

My family (excluding my caree)

My own health is suffering

The holidays

Please add your own reason

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* 3. When was your last break?

Within the past month

Within the past three months

Within the past six months

Within the past year

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* 4. Why is it difficult to get a break? Please select all that apply.

I can't find an organization that provides respite services so I can take a break.

I can't find qualified help to take care of my caree so I can take a break.

I don't feel like I have a good way to spend my break, like spending time with friends or doing something enjoyable.

I don't have the energy to organize the break.

I don't have the money to hire help for my caree so I can take a break.

I don't have the time to organize the break.

I feel too guilty to take a break.

I have no idea what I would do during a break.

I’m worried about COVID so am isolating with my caree.

My caree needs me too much to take a break.

Other (please specify)

Getting a Break

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* 1. On a scale from 1 to 5, with 1 being the least stressed and 5 being the most stressed, how stressed are you?

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* 2. What's the cause of your stress? Check as many as appropriate.

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* 3. When was your last break?

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* 4. Why is it difficult to get a break? Please select all that apply.

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* 5. What does taking a break mean to you?

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* 6. What kind of break would you love to take?

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* 7. What kind of help would allow you to take a break?