Section 1: About You Name Email Company Code Phone Number Best time to reach you Section 2: About Your Loved one Who are you caring for or concerned about? Parent Spouse/Partner Grandparent In-law Other relative Close friend What health conditions or challenges are they experiencing? (Check all that apply) Alzheimer's or Dementia Parkinson's Disease Stroke / Stroke Recovery Lewy Body Dementia Heart Disease Diabetes Mobility Issues / Fall Risk Recent Surgery Recently Hospitalized Cancer General Aging / Frailty Other Where is your loved one currently living? At home alone At home with spouse At home with family In assisted living In a nursing home / skilled nursing In hospital / rehab now Section 3:Your Current Situation How much time do you currently spend on caregiving per week? Less than 5 hours 5-10 hours 10-20 hours 20-40 hours 40+ hours Not yet, but expecting to How is caregiving affecting your work? (Check all that apply) Missing work / arriving late / leaving early Difficulty concentrating Turning down projects or promotions Considering reducing hours Thinking about leaving my job Not affecting my work yet How would you describe your current stress level around caregiving? Minimal stress, I've got this handled Some stress, manageable for now Moderate stress, starting to feel the weight High stress, struggling to keep up Overwhelmed, I need help now Section 4: What Would Help you Most What kind of support are you looking for? (Check all that apply) Education — I need to understand their condition and what to expect Guidance — I need help making decisions (home care, assisted living, etc.) Home care — I need help finding caregivers or home health services Crisis support — Something is happening right now and I need help Emotional support — I'm burnt out and need someone to talk to Planning ahead — They're okay now, but I want to be prepared Submit