Survey Form for Caregivers

1. Your Name (required)

2. Your Email (required)

3. Have you been / are you Caregiver to a family member or significant other?
 Yes No

4. If yes to (3) above, who are / were you looking after and what was the reason this person needs / needed your care?

5. What are the key issues & problems that you face(d) ?

6. What is the kind of help and support you wish was available for caregivers in similar circumstances?

7. Do you know others in your close circle who are or have been Caregivers to family members or significant others?

 Yes No

8. Based on your perception of their experiences, please describe the key issues they face(d).

9. Do you know organisations & individuals in India working with Caregivers?

 Yes No

10. If yes, please give us their details here and let us know if you can help us contact them.

11. Would you consider engaging with Caregivers Link in a professional way, either full time, part time, on a project basis or as a volunteer?

 Yes No

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