Pre-Family Caregiver Workshop Survey What is today’s date? * (MM/DD/YYYY) Enter your birthday * (MM/DD/YYYY) First * First Last Last Email My knowledge about caregiving is * Excellent Good Fair Poor My understanding of dementia is * Excellent Good Fair Poor My confidence in being a caregiver is * Excellent Good Fair Poor My understanding of where to find help and resources is * Excellent Good Fair Poor My overall health is * Excellent Good Fair Poor My knowledge of how to care for the physical needs of my care recipient is * Excellent Good Fair Poor My confidence in taking charge of my loved one’s health is * Excellent Good Fair Poor We would like to follow up with you in 30-45 days after your participation in this program. * I approve a follow up contact. I do not approve a follow up contact. Remember that your approval helps us to ensure that our programs are of value to our community. If you are human, leave this field blank. Submit
