Name
*
First Name
Last Name
Email
*
Please list any programs or organizations that have referred and/or encouraged you to participate in CRAFT Connect Family Support.
USARA
New Roads Behavioral Health
Foundation for Reovery
Other
If other:
Please enter your zip code.
If this is your Post-survey how many sessions did you participate in?
Emotional/mental well-being?
Good
Fair
Poor
Physical well-being?
Good
Fair
Poor
Relationship well-being?
Good
Fair
Poor
Emotional/mental well-being?
Good
Fair
Poor
Physical well-being?
Good
Fair
Poor
Relationship well-being?
Good
Fair
Poor
I know how to improve my family's well-being.
Strongly disagree
Disagree
Neutral
Agree
Strongly Agree
I have the skills needed to improve my family's well-being.
Strongly disagree
Disagree
Neutral
Agree
Strongly Agree
I am confident I can improve my family's well-being.
Strongly disagree
Disagree
Neutral
Agree
Strongly Agree
I often think I can't do anything to improve my family's well-being.
Strongly disagree
Disagree
Neutral
Agree
Strongly Agree
My sleep is disturbed
Yes, regular basis
Yes, sometimes
No
Caregiving is inconvenient
Yes, regular basis
Yes, sometimes
No
Caregiving is a physical strain
Yes, regular basis
Yes, sometimes
No
Caregiving is confining
Yes, regular basis
Yes, sometimes
No
There have been family adjustments
Yes, regular basis
Yes, sometimes
No
There have been changes in personal plans
Yes, regular basis
Yes, sometimes
No
There have been other demands on my time
Yes, regular basis
Yes, sometimes
No
There have been emotional adjustments
Yes, regular basis
Yes, sometimes
No
Some behavior is upsetting
Yes, regular basis
Yes, sometimes
No
It is upsetting to find the person I care for has changed so much from his/her former self
Yes, regular basis
Yes, sometimes
No
There have been work adjustments
Yes, regular basis
Yes, sometimes
No
Caregiving is a financial strain
Yes, regular basis
Yes, sometimes
No
I feel completely overwhelmed
Yes, regular basis
Yes, sometimes
No
Total your responses. "Yes, regular basis" equals 2 points. "Yes, sometimes" equals 1 point. Scoring ranges from 0 to 26, with 0 indicating no caregiver strain and 26 indicating extreme strain.