Carers Wellbeing Survey Question Title * 1. Please enter your details Name Email Address Phone Number Question Title * 2. What is the condition of the person you care for? ADHD Aspergers Autistic Spectrum Disorder Dementia Learning Disability Mental Health Multiple Disabilities Older Person Physical Disability Physical Illness Substance Misuse Other (please specify) Question Title * 3. How are you coping with your caring role at this time? Not at all Not very well OK Well Very well Not at all Not very well OK Well Very well Question Title * 4. Do you have any support with carrying out your caring role? Yes, I have a lot of support I have some support I have no support Question Title * 5. Has your caring role changed due to the Coronavirus? I am providing more care than before I am providing less care than before My caring role has not changed Other Comments Question Title * 6. Are you able to access food for yourself and the person you care for? Yes Yes but I struggle No Question Title * 7. Are you able to access prescriptions / medication for yourself and / or the person you care for? Yes Yes but I struggle No N/A Question Title * 8. Are you experiencing financial difficulty during lockdown? Yes No Question Title * 9. Are you experiencing difficulties with any of the following: Paying Bills Paying for essential items Employment issues Benefit issues Question Title * 10. Would you like support to apply for a grant for any essential items? Yes, I would like more information about this No Question Title * 11. Please rate your physical Health at this time Very bad Not great OK Good Very good Very bad Not great OK Good Very good Question Title * 12. Do you feel your physical health has deteriorated since lockdown began? Yes No Question Title * 13. Please rate your mental health at this time Very bad Not great OK Good Very good Very bad Not great OK Good Very good Question Title * 14. Do you feel your mental health has deteriorated since lockdown began? Yes No Question Title * 15. Are you experiencing any difficulties with the following: Feeling isolated Having no time for yourself Not being able to take exercise Lack of activities or stimulation for yourself or the person you care for Question Title * 16. Would you be interested in any of our online groups and activities? Yes, I would like more information about this No Tell us more Question Title * 17. Would you benefit from accessing emotional support at this time? Yes No Question Title * 18. As a Carer which ways of getting support are important to you? Telephone support Online support Face to face appointments and groups All of the above None of the above Question Title * 19. Please use this space to comment on anything else Done
