Name *

First Name

Last Name

Phone *

(###)

###

####

Are you a family caregiver or a professional caregiver? *

A family caregiver is a family member or friend who is the primary caretaker of an older adult.

Family Caregiver

Professional Caregiver

Activities of Daily Living

Are you helping a loved one with any of these daily tasks?

Taking baths or showers

Getting dressed or choosing clothes

Using the bathroom or incontinence care

Grooming: brushing teeth or hair, shaving

Eating

Walking

Transitions: getting up or down from a chair, in or out of bed or a car

Instrumental Activities of Daily Living

Check any activities for which your loved one needs full or partial assistance.

Using the phone

Shopping

Preparing meals

Light housework (washing dishes, taking out trash)

Heavy housework (laundry, vacuuming, dusting)

Going up and down stairs

Handling money or personal finances

Managing medications

Transportation (managing driving or public transit)

Overall indoor and outdoor mobility

GOAL-Tech *

Interested in receiving an ipad and learning how to use it?

Yes

No