Caregiver Survey

Caregiver Support Group - Peer Matching Survey

* Indicates required field

What is your name? *

Who do you serve as a caregiver? *

Daughter Son Wife Husband Other

If Other please specify: *

How old is the person you serve as a caregiver? *

Less than 13 19-25 26-35 36-50 Over 50

What is your age? *

19-25 26-35 36-50 Over 50

How long have you served in your role as caregiver? *

Less than 1 year 1-3 years 3-6 years 7-10 years More than 10 years

Please select the two (2) traits you feel best describe you as a caregiver. *

Patient Attentive Dependable Trustworthy Compassionate

Please choose up to two traits you feel best describe you.

Please select the two options below that best describe your struggles/challenges as a caregiver. *

Exhausted Impatient Guilty Uninformed Isolated Angry Disorganized

If you would like to receive text reminders for meetings, please enter your cell phone number below. *

If you would like to receive e-mail reminders, please enter your e-mail address below. *

Submit

500 Chase Park South Suite 130 Hoover, AL 35244
Phone: (205) 823-3818 or 1-800-433-8002
Fax: (205) 823-4544
E-mail: info@ahif.org

Improving the quality of life for survivors of traumatic brain injury and for their families