--- generated_by: surveylegend-page-markdown title: Caregiver Support Intake Form | SurveyLegend description: Plan a first caregiver support conversation with seven optional questions about practical needs, existing help, contact preferences, and next steps. canonical: https://www.surveylegend.com/survey-examples-templates/healthcare-and-hospital-surveys/caregiver-intake-form-template/ --- # Caregiver Support Intake Form Template This caregiver support intake form helps a support team understand what an adult unpaid caregiver wants help with first. Seven optional questions cover existing help, a practical priority, barriers to accessing support, and a preferred follow-up route. [Try this template ](https://app.surveylegend.com/register/)[Preview template](https://www.surveylegend.com/survey-examples-templates/healthcare-and-hospital-surveys/caregiver-intake-form-template/#try-template) Preview on a device Show the desktop survey layout Show the tablet survey layout Show the mobile survey layout ![](https://www.surveylegend.com/survey-template-media/demo-backgrounds/caregiver-intake-form-template-background.avif) **SurveyLegend** 1 / 7 Caregiver Support Intake Form Which description best fits your unpaid caregiving situation? I regularly support an adult relative I regularly support an adult friend or neighbor I share support for more than one adult +3 more answer choices Next → Caregiver Support Intake Form [Preview](https://www.surveylegend.com/survey-examples-templates/healthcare-and-hospital-surveys/caregiver-intake-form-template/#try-template) Share [Facebook ](https://www.facebook.com/sharer/sharer.php?u=https%3A%2F%2Fwww.surveylegend.com%2Fsurvey-examples-templates%2Fhealthcare-and-hospital-surveys%2Fcaregiver-intake-form-template%2F)[LinkedIn ](https://www.linkedin.com/sharing/share-offsite/?url=https%3A%2F%2Fwww.surveylegend.com%2Fsurvey-examples-templates%2Fhealthcare-and-hospital-surveys%2Fcaregiver-intake-form-template%2F)[X ](https://x.com/intent/tweet?url=https%3A%2F%2Fwww.surveylegend.com%2Fsurvey-examples-templates%2Fhealthcare-and-hospital-surveys%2Fcaregiver-intake-form-template%2F\&text=Caregiver%20Support%20Intake%20Form%20Template)[Reddit](https://www.reddit.com/submit?url=https%3A%2F%2Fwww.surveylegend.com%2Fsurvey-examples-templates%2Fhealthcare-and-hospital-surveys%2Fcaregiver-intake-form-template%2F\&title=Caregiver%20Support%20Intake%20Form%20Template) This caregiver support intake form helps a support team understand what an adult unpaid caregiver wants help with first. Seven optional questions cover existing help, a practical priority, barriers to accessing support, and a preferred follow-up route. Caregiving arrangements differ from one household to the next. A short intake can make the first conversation more useful without asking for the care recipient’s medical history. Adapt this SurveyLegend questionnaire to the resources your service actually provides. ## When to Use This Template Use the form when a caregiver first approaches a resource-navigation, peer-support or practical-help service. The caregiver is the respondent, and the focus is support for that person. Other [healthcare templates ](https://www.surveylegend.com/survey-examples-templates/healthcare-and-hospital-surveys/)address patient experiences; this form does not assess treatment or the care recipient's condition. **Create your caregiver support intake form in SurveyLegend** Caregiving arrangements differ from one household to the next. A short intake can make the first conversation more useful without asking for the care recipient’s medical history. ## 7 Caregiver Support Intake Form Questions Tell the support team what would make a first conversation useful for you. All seven questions are optional. Do not include the name, diagnosis or medical records of the person you support. This example is not monitored for urgent needs and does not enroll you in a service. Try the survey ## A little feedback. A clearer picture. Explore this 7-question example at your own pace. Every question is optional. Preview on a device Show the survey at full desktop width Resize the survey to a tablet-width preview Resize the survey to a mobile preview with scrolling inside the frame Choose a look Use Classic: a white survey card over the background photo Use Light: dark text over a light tint covering the background photo Use Dark: light text over a dark tint covering the background photo SurveyLegend demo Question 1 of 7 ### Caregiver Support Intake Form 01 Which description best fits your unpaid caregiving situation? Choose one answer, or skip this question. I regularly support an adult relative I regularly support an adult friend or neighbor I share support for more than one adult I am preparing to start caregiving Another situation Prefer not to answer 02 What would you most like help with at a first conversation? Choose one answer, or skip this question. Finding practical support services Understanding where to ask questions Arranging a break from caregiving Finding peer or emotional support Coordinating help from others Finding learning resources I am not sure yet Another priority Prefer not to answer 03 How much of the practical help you currently need is available to you? Choose one answer, or skip this question. All of it Most of it Some of it None of it I do not currently need practical help Not sure Prefer not to answer 04 What most gets in the way of using support services? Choose one answer, or skip this question. Finding clear information Time to arrange support Service cost Transport or location Hours or appointment availability Communication or accessibility needs I have not tried to use services Nothing currently gets in the way Another barrier Prefer not to answer 05 What would you like the team to understand about your next two weeks? Share your answer, or skip this question. 06 Which format would you prefer for an initial conversation? Choose one answer, or skip this question. Phone Video call In person Written exchange I would like to discuss accessible options No preference I only want general information for now Prefer not to answer 07 What name and contact detail may the support team use, and are there times they should avoid? Share your answer, or skip this question. #### One last look Review your answers before submitting this demo. 0 answered #### Thank you for trying the survey! You’ve tried the template from the respondent’s side. Make it your own with SurveyLegend. [Create your own survey](https://www.surveylegend.com/register/) Checking submission availability… This is a demo. We count starts and submissions only. Your answers stay in your browser and are never sent or saved. **—**Starts **—**Submissions Activity is temporarily unavailable. ## How to Adapt the Questionnaire List only support areas your team can discuss or signpost responsibly. Explain the service's scope, who reviews the form, expected contact arrangements, and how to reach the team another way. Keep the care recipient’s identifying details out of this first step. Before adding personal questions, review the principles for [sensitive questions ](https://www.surveylegend.com/survey-questions/sensitive-survey-questions/)and collect only what the conversation requires. ## When to Ask Share it before the first support conversation, with an option to complete it together. Avoid making form completion a prerequisite to asking for help. Revisit the priority at the conversation because a caregiver's immediate circumstances may have changed. ## How to Use the Responses Start with the priority in question 2, then use questions 3 and 4 to explore why useful support is missing or difficult to reach. Someone with little available help may still prefer information before a service referral. Confirm that preference. Do not calculate a burden score or infer the safety of a care arrangement. For service planning, summarize recurring barriers without identifying caregivers or the people they support. ## What the Research Adds Black and colleagues (2013) examined baseline data from 246 informal caregivers in Baltimore. Their abstract identifies unmet needs for “resource referrals and caregiver education.” That finding supports asking separately about the help someone wants and the barriers to reaching it. Read the [caregiver unmet-needs study ](https://agsjournals.onlinelibrary.wiley.com/doi/abs/10.1111/jgs.12549). The study involved dementia caregiving; this broader intake is an original conversation aid, not its clinical needs assessment. ## Frequently asked questions ### Who should fill this out? The adult unpaid caregiver seeking support should answer for themselves. This version is not a patient intake or a questionnaire for professional care staff. ### Does the form enroll someone in a service? No. It prepares a conversation. Explain the actual next step and confirm availability before suggesting that any support has been arranged. ### Can a staff member help complete it? Yes, if the caregiver wants assistance. Record the caregiver’s answers without substituting the staff member’s judgment, and allow any question to be skipped. ## Printable Caregiver Support Intake Form Provide the exact seven fields as a readable paper intake, with extra space for the two written answers and contact preferences. Offer assisted completion and give a specific staff recipient or private return route. Store and review completed paper through the service's agreed process. Paper responses need separate review or manual entry; they are not automatically added to online results. ![First page of the printable Caregiver Support Intake Form Template with questions and answer spaces](https://www.surveylegend.com/survey-template-media/pdf-previews/caregiver-intake-form-template-pdf-preview.avif) [![](https://www.surveylegend.com/user-guide-media/icons/download-pdf.svg) Download the questionnaire](https://www.surveylegend.com/downloads/survey-templates/caregiver-support-intake-form-template.pdf) Export Caregiver Support Intake Form as PDF ## AI Prompt: Caregiver Support Intake Form Copy this caregiver support intake form prompt into an AI assistant to prepare the questionnaire. Review the result, then build and customize it in SurveyLegend. 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