Personal Questionnaire

Basic Information

This questionnaire covers information about your relationship with your care partner, their needs and supports, your needs and supports, and your goals for joining the cohort.

This questionnaire may take up to 30 minutes to complete.

We know this can get personal so you are welcome to take your time in thinking through your responses.

We respect you and your rights to privacy so all responses will be handled with care by AKALAKA to better support you and your care partner and in accordance with our Privacy Policy and Notice of Privacy Practices detailed on the website: https://www.akalaka.org

Questions? Contact: [email protected]

My name

My phone number

I care about, and am primarily joining this cohort to better care for ___________ who has the Innovations Waiver.

my sibling

my child

my significant other

my parent

my friend

Other

My stage of caregiving:

A

I have not had to think about caregiving responsibilities

B

In the near future, I may take on caregiving responsibilities

C

I am starting to take on caregiving responsibilities

D

I am the sole or primary person caregiving

E

I am a secondary person caregiving

F

I am a backup person caregiving

G

I anticipate supporting the primary person caregiving

H

I am transitioning caregiving responsibilities to someone else

I

I no longer have caregiving responsibilities

J