Contact Information

In order to respond, your name and email are required. A summary report will be sent to you within 2 business days. The report is for your use only and will not be shared. We will not contact you unless requested. There is no cost or obligation.

Caregiving at a Distance Survey

Instructions: Once you fill out the survey, please provide a name and email address in the sign up. You will then be sent a summary report providing you several options. It will not be shared with anyone, and is only for information purposes.

You have the option of calling us at 774-377-5818 or emailing us for further information and access to additional services and products. There is no obligation.

Questions 1 to 8 are required.

Thank You.

1. Who are you planning care for?

2. Loved one's gender?

3. Loved one's age?

4. Loved one’s Illness condition?

Select all that apply.

5. Where is your loved one receiving caregiving or where do you plan to manage caregiving for you loved one?

6. What are your major caregiving concerns for your loved one?

Select all that apply.

7. What are your current caregiver or anticipated caregiver issues?

Select all that apply.

* Legal papers include power of attorney, medical directives, financial control.

8. How far away is your loved one living?

9. If you wish, please provide additional information.

Please keep to 1500 characters (approx. 230-250 words.)