TCARE Screener

This Screener is for unpaid family caregivers.
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Today’s Date

 
Name

 
Phone

 
Email

 
Address

 
County of Residence

 
Are you the person most responsible for caring for an adult, such as your spouse, partner, parent, relative or friend, (care receiver*)?
* Care receiver means any adult (18 years or older) who needs care or supervision by an unpaid caregiver. For example, a care receiver can be your spouse, partner, parent, adult child, friend, neighbor or other relative.

     
 
Who do you care for?


 
The things I am responsible for, do not fit very well with what I want to do.

 
I am not always able to be the person I want to be when I am with my care receiver.

 
It is difficult for me to accept all the responsibility for my care receiver.

 
I am having trouble accepting the way I relate to my care receiver.

 
I am not sure that I can accept any more responsibility than I have right now.

 
It is difficult for me to accept the responsibilities that I now have to assume.

 
Instructions: The following are aspects of life that can change as a result of caregiving responsibilities. Please check the box that best reflects how you feel about each of the following statements.

 
My caregiving responsibilities have: Caused conflicts with my care receiver.

 
My caregiving responsibilities have: Decreased time I have to myself

 
My caregiving responsibilities have: Created a feeling of hopelessness.

 
My caregiving responsibilities have: Given my life more meaning.

 
My caregiving responsibilities have: Increased the number of unreasonable requests made by my care receiver.

 
My caregiving responsibilities have: Kept me from recreational activities.

 
My caregiving responsibilities have: Made me nervous.

 
My caregiving responsibilities have: Made me more satisfied with my relationship with the care receiver.

 
My caregiving responsibilities have: Caused me to feel that my care receiver makes demands over and above what he/she needs.

 
My caregiving responsibilities have: Caused my social life to suffer.

 
My caregiving responsibilities have: Depressed me.

 
My caregiving responsibilities have: Given me a sense of fulfillment.

 
My caregiving responsibilities have: Made me feel I was being taken advantage of by my care receiver.

 
My caregiving responsibilities have: Changed my routine.

 
My caregiving responsibilities have: Made me anxious.

 
My caregiving responsibilities have: Left me feeling good.

 
My caregiving responsibilities have: Increased attempts by my care receiver to manipulate me.

 
My caregiving responsibilities have: Given me little time for friends and relatives.

 
My caregiving responsibilities have: Caused me to worry.

 
My caregiving responsibilities have: Made me enjoy being with my care receiver more.

 
My caregiving responsibilities have: Left me with almost no time to relax.

 
My caregiving responsibilities have: Made me cherish my time with my care receiver.

 
Instructions: Please indicate how often have you felt the following during the past week?

 
I was bothered by things that usually don’t bother me.


 
I had trouble keeping my mind on what I was doing.


 
I felt depressed.


 
I felt that everything I did was an effort.


 
I felt hopeful about the future.


 
I felt fearful.


 
My sleep was restless.


 
I was happy.


 
I felt lonely.


 
I could not “get going.”


 
Please indicate which of the following best describes your care receiver's memory.


 
Given your care receiver’s CURRENT CONDITION, would you consider having him or her move to an out-of-home, long-term care setting?


Thank you for participating in the Washington State’s Personal Family Caregiver Survey!
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