HJM4 Family Caregivers Task Force
Family Caregiver Survey
Thanks for your time in completing the following survey. Your input will help to inform the The New Mexico State Plan for Family Caregivers, to be released by Fall 2015.
Completed surveys may be returned to:
Myles Copeland / Aging and Long-Term Services Department /
PO Box 27118 / Santa Fe, NM 87502 or
1. / Are you a (Check all that apply):___ Current caregiver
___ Former caregiver
___ A potential caregiver
___ Person who is receiving care from a loved one
___ A provider of services
___ A friend or relative of a caregiver
___ A person who works in public policy
___ A provider of services for caregivers
3.
2. If you are currently or formerly a caregiver, what type of care did you provide? (Check all that apply)
___ Assistance with daily living tasks
___ Preparing meals
___ Help with finances
___ Wellness checks
___ All of the above
3. Have you as a caregiver experienced challenges in providing care or arranging for services?
___ Yes
___ No
4. If you answered yes to question 3, please share what challenges you have encountered?
5. As a caregiver, have you experienced difficulty with the following (check all that apply):
___ Bathing
___ Dressing
___ Housing
___ Information
___ Meals
___ Medical care management
___ Medication management
___ Personal finances
___ Respite
___ Social activities
___ Work
___ Transportation
___ Other (Please specify in the space below)
6. While being a caregiver, were you aware of, or did you take advantage of, any outside resources?
___ Yes
___ No
7. If your answer to question 6 was yes, can you briefly describe what those resources were?
8. What information or resources would be/would’ve been helpful to you? Please briefly describe.
9. Do you have a personal story – a joy or challenge – you experienced while caregiving that you would like to share? If so, please do so below.
2