Caregiving Support Assessment

Things to Consider

Select the number (on a scale of 1-3) that best describes your situation for each item or issue. You can total your scores if you wish to get a big picture of the situation. Lower scores indicate less manageable situations -- situations requiring additional support beyond the primary caregiver -- and higher scores indicate situations that may be more readily managed.

For the care recipient and caregiver:

_____ (1) There are no community support services available

_____ (2) There are some community support services available such as transportation, meals

_____ (3) There is support ready and available to help with long-term care

For the care recipient and caregiver:

_____ (1) There are no informal support groups available

_____ (2) There are inadequate informal support groups

_____ (3) There are networks of informal support available through neighbors, family and

friends, or religious groups

The primary caregiver:

_____ (1) Does not "believe in" accepting help of any kind from anyone

_____ (2) Does not "believe in" accepting help from anyone outside the family

_____ (3) Is open to accepting help from others

The primary caregiver:

_____ (1) Is essentially cut off from participating in social or recreational activities

_____ (2) Is significantly restricted in participating in social or recreational activities

_____ (3) Is able to continue to participate in at least one important social or

recreational activity

The primary caregiver:

_____ (1) Will be isolated from previous activities/relationships with significant others

_____ (2) Relationships outside the home will be significantly restricted

_____ (3) Relationships with significant others can continue on a regular, if somewhat reduced,

basis

The primary caregiver:

_____ (1) Will be essentially cut off from participation in valued religious activities

_____ (2) Will be significantly restricted from participation in valued religious activities

_____ (3) Will be able to maintain participation in valued religious activities

Scoring

Lower scores indicate less manageable situations -- situations requiring additional support beyond the primary caregiver -- and higher scores indicate situations that may be more readily managed.

Lowest possible rating score for this section: 6 **

** indicates a need for significant caregiver support

Highest possible rating score for this section: 18

Your total rating score for this section: