Caregiver Survey

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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

Is your loved one currently an AHIF client? *

Yes No Not Sure

Please indicate the AHIF Support Specialist you have communicated with *

Marilyn Davis Bethany Leonard Aimee Lott Pat Motley Jenn O'Dell Briana Reed Cindy Woodcox I don't remember the name I have never worked with an AHIF Support Specialist

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. *

Thank you for taking time to complete this survey. Click the "Submit" button below to submit your survey responses.

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: [email protected]

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