Caring for the Caregiver, Group Interest Form, Women's Resource Center

About You

First name

Last name

Email address

Phone number (optional)

City / Town

How did you hear about this group?

Your Caregiving Situation

Who do you provide care for? (relationship)

How long have you been in this caregiving role?

Which of the following best describes the person you care for? (select all that apply)

An older adult (65+)

Someone with a physical disability or chronic illness

Someone with a cognitive condition such as dementia or Alzheimer's

Someone with a mental health condition

Other

On a typical week, approximately how many hours do you spend on caregiving tasks?

Group Fit and Readiness

These questions help us understand what you're looking for and make sure the group format is a good match for you right now.

In your own words, what is bringing you to this group right now?

Have you participated in a support group or counseling before?

Yes, and it was helpful

Yes, mixed experience

Yes, it did not go well

No, this would be my first

For each statement below, select the response that feels most true for you right now.

I feel like I have enough emotional steadiness right now to engage with a support group, even if I also feel overwhelmed at times.

Not at allVery true

When I hear others share difficult emotions or painful experiences, I generally feel able to stay present without becoming overwhelmed myself.

Not at allVery true

In recent weeks, I have generally been able to manage my day-to-day responsibilities, even if it has felt hard.

Not at allVery true

I have at least one person in my life I can reach out to if I am having a very difficult day or feel like things are becoming unmanageable.

Not at allVery true

Right now, I am going through something so acute or overwhelming that I feel I need more individual support before I would be ready to participate in a group setting.

Not at allVery true

Are you currently working with a therapist, counselor, or mental health provider?

Yes, actively

Yes, occasionally

No, but open to it

No, and I don't feel I need it

In the past 3 months, have you experienced any of the following? (select all that apply)

A hospitalization or medical crisis of my own

A hospitalization or medical crisis of the person I care for

A significant loss (death, relationship, housing, employment)

An experience I would describe as traumatic

None of the above

Is there anything else you think it would be helpful for us to know as we review your interest form?

This group meets weekly for 10 weeks via Zoom. How confident are you that you can attend most sessions?

Very confident

Fairly confident

Unsure

It may be difficult

Women's Resource Center

Caring for the Caregiver
Group Interest Form

Thank you for applying.

Staff Access

Clinical Screening Review

Women's Resource Center

Caring for the CaregiverGroup Interest Form

Thank you for applying.

Staff Access

Clinical Screening Review

Caring for the Caregiver
Group Interest Form