HealthCircle Aging Center 4863 North Nevada Avenue, Suite 321 Colorado Springs, CO 80918 office 719-255-8002 fax 719-255-8006 CLIENT DATA FORM: CAREGIVER FAMILY THERAPY CAREGIVER CHARACTERISTICS CG#:________ (for admin only) CAREGIVER NAME: ______________________________________ DATE: __________ DOB: ________ AGE:_______ LAST FOUR DIGITS OF SOCIAL SECURITY NUMBER (for grant funding): __ __ __ __ STREET ADDRESS: ______________________________________ CITY: ______________________________ STATE: ____________ ZIP: __________ PHONE: ____________________________ E-MAIL: ______________________________________ CURRENT LIVING SITUATION: __________________ WITH WHOM DO YOU LIVE? ____________________ DO YOU LIVE IN A RURAL AREA? Y N (Urban areas include: 80903-7, 80909-11, 80915-23) HIGHEST GRADE IN SCHOOL COMPLETED/ DEGREE OBTAINED: _____________ CURRENTLY EMPLOYED? YES NO CURRENT OCCUPATION (IF RETIRED, LIST FORMER OCCUPATION): _________________ ANNUAL INCOME RANGE (for research and grant funding): _________________________ NUMBER OF PEOPLE SUPPORTED BY INCOME: ___________ SOURCE OF INCOME: _________________________ DISABLED: Y N (If yes, please list disability): _________________________________ USER OF OTHER OLDER AMERICANS ACT SERVICE (SEE ATTACHED FORM): Y N RELATIONSHIP TO THE PERSON RECEIVING CARE (CARE RECIPIENT): _________________ (While we consider the below questions important to offer you the best services possible, responses are optional.) PARTNER STATUS: Divorced Legally Separated Married Domestic Partner Single Widowed GENDER: _________________________________ RACE/ETHNICITY: African-American/Black, American Indian, Asian, Hispanic/Latino, Native Hawaiian/Pacific Islander, White, Multiracial SEXUAL ORIENTATION: _________________________________ SPIRITUALITY/RELIGIOUS AFFILIATION: _________________________________ © Aging Center 12/2014 CARE RECIPIENT CHARACTERISTICS CARE RECIPIENT NAME: ______________________________________ DOB: ________ AGE:_______ LAST FOUR DIGITS OF SOCIAL SECURITY NUMBER (for grant funding): __ __ __ __ STREET ADDRESS: ______________________________________ CITY: ______________________________ STATE: ____________ ZIP: __________ PHONE: ____________________________ E-MAIL: ______________________________________ CURRENT LIVING SITUATION: __________________ WITH WHOM DO YOU LIVE? ____________________ DO YOU LIVE IN A RURAL AREA? Y N (Urban areas include: 80903-7, 80909-11, 80915-23) HIGHEST GRADE IN SCHOOL COMPLETED/ DEGREE OBTAINED: _____________ CURRENTLY EMPLOYED? YES NO CURRENT OCCUPATION (IF RETIRED, LIST FORMER OCCUPATION): _________________ ANNUAL INCOME RANGE (for research and grant funding): _________________________ NUMBER OF PEOPLE SUPPORTED BY INCOME: ___________ HOW ARE THE CARE RECIPIENT’S EXPENSES PAID? ___________________________________ DISABLED: Y N (If yes, please list disability): _________________________________ USER OF OTHER OLDER AMERICANS ACT SERVICE (SEE ATTACHED FORM): Y N RELATIONSHIP TO THE PERSON PROVIDING CARE (CAREGIVER): _________________ (While we consider the below questions important to offer you the best services possible, responses are optional.) PARTNER STATUS: Divorced Legally Separated Married Domestic Partner Single Widowed GENDER: _________________________________ RACE/ETHNICITY: African-American/Black, American Indian, Asian, Hispanic/Latino, Native Hawaiian/Pacific Islander, White, Multiracial SEXUAL ORIENTATION: _________________________________ SPIRITUALITY/RELIGIOUS AFFILIATION: _________________________________ PLEASE DESCRIBE YOUR MAIN CONCERN(S) ABOUT THE CARE RECIPIENT: PLEASE DESCRIBE AN AVERAGE DAY WITH THE CARE RECIPIENT: © Aging Center 12/2014 HealthCircle Aging Center 4863 North Nevada Avenue, Suite 321 Colorado Springs, CO 80918 office 719-255-8002 fax 719-255-8006 r Medication List Name of Primary Physician: ______________________________________ Address: ______________________________________________________ Phone Number: __________________________ Fax Number: ____________________________ Prescription Medications Reason Taken Dose/ Frequency Time of Day (AM, PM, etc.) Over-the-Counter Medications Reason Taken Dose/ Frequency Time of Day (AM, PM, etc.) Please list your current health problems/conditions: 2015 HHS Poverty Guidelines Persons in Family Unit 48 Contiguous States and D.C. 1 $ 11,770 2 $ 15,930 3 $ 20,090 4 $ 24,250 5 $ 28,410 6 $ 32,570 7 $ 36,730 8 $ 40,890 For each additional $ person, add 4,160 Services under the Older Americans Act Senior Information and Assistance Center—PPAAA low income dental program Family Caregiver Support Center—PPAAA caregiver assistance & planning program Senior Insurance Assistance—Medical insurance counseling & claims assistance Long-Term Care Ombudsman Program—PPAAA 2-1-1—Information & assistance Comfort Keepers—Home care & personal care Colorado Legal Services—Legal counseling Disability Services of Colorado—Hearing aid assistance El Paso/Fountain Valley Senior Services—Transportation & rural frozen meal delivery Golden Circle Nutrition Program—Housing Authority of the City of C/S—Congregate meals & nutrition education Mountain Community Transportation Park County Senior Coalition—Transportation, homemaker services, home safety renovations, chore services, & rural meal delivery Prospect Home Care and Hospice—Telephone reassurance & homemaker/personal care Silver Key Senior Services—Transportation & telephone reassurance Teller Senior Coalition—Transportation, caregiver information & counseling services, home safety renovations, & rural meal delivery HealthCircle Aging Center 4863 North Nevada Avenue, Suite 321 Colorado Springs, CO 80918 office 719-255-8002 fax 719-255-8006 AUTHORIZATION TO RELEASE RECORDS AND INFORMATION I, ___________________________________, give my permission to release copies of the following records and/or information:_______________________________________________ about myself to/from_____________________________________________________________ (Name of Person/Agency/Organization/Physician) ______________________________________________________________________________ (Address) __________________________________ (Phone) __________________________________ (Fax) This authorization will be in effect from _____________________, until___________________ (Date) (Date) I understand that I give my permission for the records and/or information to be obtained from or released to only the person(s) or organization(s) indicated above, and relating only to the time period(s) indicated above. I understand that if the information is released to my physician, it may become part of my medical record in my physician’s office. I understand that there are a few limited exceptions to these provisions in the Colorado Statutes. These require the reporting of threats of violence, harm, or child or elder abuse and neglect (from either evidence or suspicion), or when subpoenaed by the courts, to proper authorities. Certain other exceptions exist and will be explained as necessary. The UCCS Aging Center may not obtain or release records and/or information about me unless I agree to the request to do so. I understand that I may revoke this consent at any time in writing, or if I am physically unable to write, by orally advising the UCCS Aging Center, except to the extent that the action has been taken thereon. ________________________________ Client or Guardian Signature ______________ Date ________________________________ Witness (Clinician) Signature ______________ Date ___ ___-___ ___-___ ___ ___ ___ Date of Birth This page intentionally left blank 15-164, O’Malley V1, 4/28/2016 HealthCircle Aging Center 4863 North Nevada Ave, Suite 321 Colorado Springs, CO 80918 office 719-255-8002 fax 719-255-8006 CLIENT RIGHTS AND CONSENT TO TREATMENT CLIENT: _______________________________________ DATE: _________________________ This information regarding your rights as a client is provided to you, as required by law. The Aging Center is a university-based training and research facility, which specializes in preparing graduate students for professional practice in psychology. All mental health professionals are required by law to provide the following information to each client (or their legal guardian) during the initial client contact, except in cases of emergencies and court ordered situations: Aging Center Clinician/Degree: ______________________________________________________ Supervisors Michael Kenny, Psy.D., P.C., License #1626 Brandon Gavett, Ph.D., License #3601 Carrie Bartell, L.C.S.W., License #876011 Daniel L. Segal, Ph.D., License #2054 Patricia Pirrello, Ph.D., License #1443 Business Address: Business Phone: Justin Lincoln, Psy.D. License # 3029 Cassie Faulhaber, Psy.D., License #3972 Miranda Shaw, Psy.D., License #3845 Sara H. Qualls, Ph.D., License #1092 4863 N. Nevada Ave., Suite #321 Colorado Springs, CO 80918 (719) 255-8002 1. All Aging Center clinicians in training serve as clinical staff and receive on-going and intensive supervision from qualified Licensed Psychologists and Licensed Clinical Social Workers. The students in training at the Aging Center are not licensed in the State of Colorado. However, the students in training follow the regulations set forth by the State of Colorado and the professional ethics code. 2. Recording of Clinical Sessions: Clients of the Aging Center are required to give signed consent for the observation and recording of sessions to facilitate training needs and progress of therapy. The information derived from observation or recording is not shared with anyone other than the Aging Center staff members, in the context of professional consultation or supervision. The recording will be erased following the supervisory or evaluation review. 3. The practice of licensed or registered persons in the field of psychotherapy is regulated by the Mental Health Section of the Division of Registrations. We encourage discussing any concerns or complaints you might have directly with the provider of your services, the supervisor of such services, or the Aging Center Director, Dr. Michael Kenny. You can also contact the Colorado State Board of Psychologist Examiners at 1560 Broadway, Suite 1350, Denver, CO, 80202, Phone: 303894-7766. 4. Other Important Information: a. Feel free to ask any questions about techniques used, the duration of the procedure, the reason for any of the policies outlined in this form, or fees for services, at any time. b. You may seek a second opinion from another clinician or may terminate our services at any time. c. In a professional relationship, sexual contact is never appropriate and should be reported immediately to the State Board of Psychologist Examiners. 5. Confidentiality: The information provided by you as a client or caregiver/legal guardian is legally confidential. There are exceptions to this confidentiality. Primarily these include: a. A judge’s order, in a court of law, to reveal information. b. If you provide your clinician with information about child abuse or elder abuse or that you intend to harm yourself or someone else, including those identifiable by their association with a specific location or entity, she or he is required by law to reveal that information to the appropriate authorities or individuals, and/or person(s) responsible for the specific location or entity. c. As of July 1, 2014, individuals 70 and older are considered at risk and situations involving suspected abuse, caretaker neglect, and/or exploitation, must be reported to local law enforcement. d. Others are listed in the Notice of Privacy Rights that was provided to you. 6. Fees: Client fees are determined on a sliding scale. Should you fail to pay your bill and decline to make arrangements to pay off an outstanding balance, we reserve the right to use appropriate collection procedures, including the use of a collection agency or court action. 7. Cancellations: Except in cases of emergency or illness, therapy appointments must be cancelled at least 24 hours ahead of time. Failure to do so may result in billing for the missed appointment. 8. If you anticipate needing to bring a family member who is a care recipient to the Aging Center, please discuss your situation with your therapist beforehand if possible. The Aging Center is not able to provide supervision of care recipients who are left in our lobby. If resources are needed to help you obtain coverage for your family member while you participate in services at the Aging Center please talk with your therapist who can assist you. If your care recipient must accompany you to your session, any assistance needed by your care recipient will result in your session being interrupted and possibly rescheduled. 9. The Aging Center is not able to provide emergency or crisis services. If you have an emergency, please go to the nearest hospital or emergency room, or call the local mental health crisis line (6357000). If you anticipate or are experiencing acute distress, you and your therapist may decide to schedule extra sessions and/or a plan to have brief phone consultations. 10. Future Contact Regarding Quality of Services: The Aging Center also may wish to contact you by mail and/or telephone to seek your opinions about the quality of services received at the Aging Center. Your cooperation with this effort will contribute to our efforts to improve services and make them more widely available. Please indicate if you wish to be contacted regarding quality of services: _____ No contact _____Yes, mail and/or phone _____Yes, mail only Z:\EVERY CONCEIVABLE FORM\CLIENT RIGHTS AND CONSENT TO TREATMENT- CAREGIVER PROGRAM 2/2015 2 CAREGIVER PROGRAM SUPPLEMENT 1. Caregiver Program Services are available at the Aging Center for six sessions with no charge, partially by way of funding through Pikes Peak Area Agency on Aging. The actual cost to the Aging Center of providing caregiver services to the community exceed $100 per session, to cover training and supervision time. Cost of similar services, if available in the private community, would typically be in the range of $75-$125 per session, per person. Tax deductible donations are welcomed and may be made to The University of Colorado Foundation/Aging Center, 4863 North Nevada Ave., Suite #321, Colorado Springs, CO 80918. 2. Client information may be shared between Center staff members in the context of professional consultation or supervision. Also, Pikes Peak Area Agency on Aging provides funding in support of the Center’s Caregiver program. Therefore, information about caregiver services you receive and how effective they were is provided for the purposes of reporting and auditing through the Pikes Peak Area Agency on Aging. 3. The Aging Center will consult with you about your family member based on information you provide. Because the Center does not have a therapist-client relationship with that person, we are unable to obtain medical or other information except through you. RESEARCH DATA 1. Use of Data for Research Purposes: With your permission, in order to advance the science of clinical psychology, the data obtained from our services will be kept in a database and analyzed for research purposes. All identifying information will be removed, so that it will be impossible to associate the data with you. Participation in research is not required in order to receive services at the Aging Center. Again, to ensure confidentiality, your name or other identifying information will not be associated with the data. Examples of service data used in research are: test scores, types of services received, ratings of service satisfaction, and levels of depression and anxiety. Please indicate if you consent to the use of your data (which will not be associated with your identity): _____Yes 2. ____No Future Contact Regarding Opportunities for Research Participation: With your permission, you may be contacted in the future and asked to participate in other research projects through the Aging Center. On such occasion, you would be fully informed and asked for your consent to participate. Participation in research is not required in order to receive services at the Aging Center. Please indicate if you permit us to contact you in the future regarding participation in research projects: _____Yes ____No If you have questions regarding use of data for research, you may contact the principal investigator and the Director of the Aging Center, Michael Kenny (719-255-8002). If you have questions regarding your rights as a research participant or any concerns regarding use of your de-identified data, you may report them – confidentially if you wish – to the UCCS Institutional Review Board (719-255-3903). IRB# 08-128, Exp 02/23/16 Z:\EVERY CONCEIVABLE FORM\CLIENT RIGHTS AND CONSENT TO TREATMENT- CAREGIVER PROGRAM 2/2015 3 Explanation of types of mental health professionals: A Licensed Psychologist must hold a doctoral degree in psychology and have completed post-doctoral supervised practice. Licensed Clinical Social Workers, Licensed Marriage and Family Therapists, and Licensed Professional Counselors must hold a master’s degree in their profession and have completed post-masters supervised practice. Psychologist Candidates, Marriage and Family Therapist Candidates, and Licensed Professional Counselor Candidates must hold the necessary degree and be in the process of completing required supervised practice. Certified Addiction Counselors must be a high school graduate and have completed required training and supervised practice (CAC I & II), or must have a bachelor’s degree in behavioral health and have completed additional training hours and supervised practice (CAC III). A Licensed Addiction Counselor must have a clinical master’s degree and meet the CAC III requirements. A Registered Psychotherapist is registered with the State, but is not licensed or certified, and is not required to have any degree, training or experience. I have read the preceding information and have also been given a verbal explanation. I understand my rights as a client or as the client’s responsible party. I hereby consent to consultation, evaluation and/or treatment by clinically qualified staff of the Aging Center. _____________________________________ Client Signature ___________________________ Date _____________________________________ Clinician Signature ___________________________ Date _____________________________________ Supervisor Signature ___________________________ Date Z:\EVERY CONCEIVABLE FORM\CLIENT RIGHTS AND CONSENT TO TREATMENT- CAREGIVER PROGRAM 2/2015 4 HealthCircle Aging Center 4863 North Nevada Avenue, Suite 321 Colorado Springs, CO 80918 office 719-255-8002 fax 719-255-8006 www.uccs.edu/agingcenter CLIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES You May Refuse to Sign This Acknowledgement I have received a copy of the Notice of Privacy Practices from ___________________________ I am a Caregiver Program client YES NO. If YES, I have also received the UCCS Aging Center Complaint and Grievance Policy. _______________________________________ Name (Print) ____________________________________ Signature __________________ Date For Office Use Only We have made a good faith effort in attempting to obtain written acknowledgement of receipt of the Notice of Privacy Practices. Acknowledgement could not be obtained for the following reason(s): Patient/Individual refused to sign. Communications barriers prohibited obtaining an acknowledgement An emergency situation prevented us from obtaining an acknowledgement Other: _____________________________________________________________ Date of refusal: _______________________ Attempt was made by: _________________________________________ Date: ___________ © UCCS Aging Center 01/2014 CG Privacy Practices Acknowledgement (V1) 1 HealthCircle Aging Center 4863 North Nevada Avenue, Suite 321 Colorado Springs, CO 80918 office 719-255-8002 fax 719-255-8006 AUTHORIZATION TO INFORM EMERGENCY CONTACT In the event that my therapist, ________________________, is concerned about my safety because he or she was unable to reach me at our scheduled appointment time, I give my permission for my therapist to contact: ___________________________________________ Name ___________________________________________ Address _______________ Phone and to inform the above named person or agency about his or her concern. I understand that no information will be released other than that related to the concern about my safety, unless legal requirements relating to the reporting of threats of violence, harm, or child or elder abuse or neglect apply. This authorization will remain in effect from _______________, until the termination of my therapy unless revoked by me in writing or by orally advising the Aging Center. ______________________________ Client or Guardian Signature ____________ Date ______________________________ Witness (Clinician) Signature ____________ Date Emergency Contact Release 5/20/2009 IRB 04-019, Kisley V2 - 9/11/14 Protocol Number: 14-251 Version and Date Received: ROC(1) V1, 7/8/15 Consent to be a Research Subject Protocol #: 14-251 Title: The UCCS Research Registry Principal Investigator: Michele Okun, PhD Funding Source: N/A Introduction UCCS and The Lane Center for Academic Health Sciences are actively seeking adults to participate in research studies. To that end, we are collecting names to form a Participant Registry database. This form is designed to tell you everything you need to think about before you decide to consent (agree) to be a part of this Registry. A member of the research team will describe the process to you and answer any questions. It is entirely your choice. If you decide to take part, you can change your mind later on and withdraw from the research registry. You can skip any questions that you do not wish to answer. This Database contains names of individuals who have expressed an interest in participating in research studies at UCCS. If you decide to participate, we will record your name, and other demographic information such as gender, year of birth, race, ethnicity, veteran/military status, phone number, email, and mailing address. Even if you decide not to provide all of this information, you can still be added to the database. Before making your decision: Please carefully read this form or have it read to you. Please ask questions about anything that is not clear. Feel free to take your time thinking about whether you would like to participate. By signing this form you will not give up any legal rights. If you are completing this consent form online, you may want to print a copy of the consent form for your records. Overview: We are asking your permission to put contact and minimal demographic information about you in a UCCS Research Registry database. This research registry will allow UCCS investigators to find individuals, such as you, who may want to take part in research. The information we are collecting includes basic information and other demographic information such as gender, year of birth, race, ethnicity, veteran/military status, phone number, email, and mailing address. We are asking all residents of the Pikes Peak region who are 18 years of age or older to participate. Procedures: If you agree to participate in this research registry, your contact information will be provided to the researchers who place a written request with the designated data manager. Only if you meet minimum eligibility requirements, such as age or gender, will your contact information be provided to the researcher. You may then be contacted by a researcher (via mail, phone or email) who will talk to you about a specific study. If you sign up for the research registry, you can still refuse to take part in any (future) research study. If you decide to take part in any research study, you must sign a separate consent form for that study. Other people in this study: We are asking all residents of the Pikes Peak region (~300000) 18+ years if he/she would be willing to be added to the Research Registry in order to be contacted for future research purposes. Risks and Discomforts: We anticipate minimal risk or discomfort with this data collection. You may have concerns about the information being collected and whether it can be connected back to you. In order to address this potential discomfort/risk, we are not collecting any personal identifying medical information from you. You will have full access to Page 1 of 3 Version Date: 05/22/2014 Protocol Number: 14-251 Version and Date Received: ROC(1) V1, 7/8/15 clinical services at any UCCS related clinic even if you do not wish to have your data used for research purposes. Services are not contingent on agreeing to have information used for future research purposes. Benefits: There are no anticipated benefits from being in this registry. However, if you do choose to participate in specific research study from which your information was provided, you may realize direct benefit from that. Compensation: Compensation is not provided for signing up for the registry. Confidentiality: None of your contact information will be publicly available. All information will be maintained in a password, encrypted database. Requesting investigators are likewise obligated to maintain your confidential information. You will not be specifically identified in any publication of research results. Only the individual consenting you and the Database Manager will be aware of your identity. Your information will be entered into a password protected and firewalled database that is only accessible by the Data Manager. Certain offices and people other than the researchers may have access to registry records. Government agencies and UCCS employees overseeing proper study conduct may look at your registry records. These offices include the: UCCS Institutional Review Board UCCS Office of Sponsored Programs UCCS will keep any research records confidential to the extent allowed by law. A study number rather than your name will be used on registry records wherever possible. Registry records may be subject to disclosure pursuant to a court order, subpoena, law or regulation. Voluntary Participation and Withdrawal from the Study Taking part in this study is voluntary. You have the right to leave a study at any time without penalty. You may refuse to do any procedures you do not feel comfortable with, or answer any questions that you do not wish to answer. If you withdraw from the study, you may request that your research information not be used by contacting the Principal Investigator listed above and below. Contact Information Contact (PI’s info): Michele Okun, PhD; 412-302-8030; mokun@uccs.edu if you have any questions about this registry or your part in it Contact the Research Compliance Specialist at 719-255-3903 or via email at irb@uccs.edu: if you have questions about your rights as a research participant, or if you have questions, concerns or complaints about the research. Consent A copy of this consent form will be provided to you. I understand the above information and voluntarily consent to participate in the research. I choose to be in this registry. By signing this consent, I am confirming that I am 18 years of age or older. Signature of Participant Page 2 of 3 Date Version Date: 05/22/2014 Protocol Number: 14-251 Version and Date Received: ROC(1) V1, 7/8/15 Please complete any or all of the following items: Name: ____________________________________ Gender: Your Year of Birth: ___________________ Phone #: ___________________________ Address: _____________________________________ Email:______________________________ _____________________________________________ Preferred method of contact: Email Please circle your ethnicity: 1. Hispanic Please circle your race: 1. White 2. Black or African American 3. Native Hawaiian or Other Pacific Islander 4. American Indian or Alaska Native 5. Asian 6. More than one race 7. Other or unknown Page 3 of 3 male female Phone 2. Non-Hispanic Please indicate your veteran or military status: 1. Veteran 2. Active Military/Reserve 3. Civilian 4. Other/NA (indicate):______________________ Version Date: 05/22/2014 This page intentionally left blank UCCS Aging Center Caregiver Program Behavior Problem Checklist In what areas do you find your family member having difficulty? Please rate the degree of problems your family member is experiencing by circling the appropriate number in each of the following areas on a scale from 1(no problem) to 7 (frequent problem or intense problem). Place a check beside the areas of functioning that have changed with in the past four to six months. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Planning Memory Follow through on plans Concentration Decision-making Anxiety/Worry Mood Depression Sadness Irritability Apathy Withdrawal Personality Changes Suspiciousness Inappropriate behavior Aggressive Behavior Suicidal Thoughts Social Relations © CU Aging Center 2/2007 No Problem 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 Frequent Problem 5 6 7 5 6 7 5 6 7 5 6 7 5 6 7 5 6 7 5 6 7 5 6 7 5 6 7 5 6 7 5 6 7 5 6 7 5 6 7 5 6 7 5 6 7 5 6 7 5 6 7 5 6 7 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 Energy Level Medical Problems Isolation Driving Household Tasks Falls/Balance Safety Issues Sleep Self-care/Hygiene Medical Care Nutrition Appetite Incontinence Homicidal Thoughts Other: Other: No Problem 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 Frequent Problem 4 5 6 4 5 6 4 5 6 4 5 6 4 5 6 4 5 6 4 5 6 4 5 6 4 5 6 4 5 6 4 5 6 4 5 6 4 5 6 4 5 6 4 5 6 4 5 6 CG Behavior Problem Checklist (V1.2) 1 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 Instrumental/Activities of Daily Living Assessment Form Please rate the degree of problems your family member is experiencing by circling the appropriate number in each of the following areas on a scale from 1(no assistance) to 7 (full assistance). Place a check beside the areas of functioning that have changed with in the past four to six months. 1 2 3 4 5 6 7 8 9 No Assist Bathing 1 2 Grooming 1 2 Ambulation 1 2 Dressing 1 2 Transfers ** 1 2 Eating 1 2 Toileting 1 2 Access Resources 1 2 Household Tasks 1 2 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 Full Assist 5 6 7 5 6 7 5 6 7 5 6 7 5 6 7 5 6 7 5 6 7 5 6 7 5 6 7 No Assist 10 Heavy Chores 1 2 11 Transportation 1 2 12 Financial Management 1 2 13 Shopping 1 2 14 Food Preparation 1 2 15 Medication Administration 1 2 16 Laundry 1 2 17 Telephone 1 2 18 Appointment Management 1 2 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 Full Assist 5 6 7 5 6 7 5 6 7 5 6 7 5 6 7 5 6 7 5 6 7 5 6 7 5 6 7 ** example of ‘Transfers’ is getting in & out of chair/bed Attributions Please give your opinion about what you think is creating these problems? Normal Aging Problems Dementia/Alzheimer’s Depression or Anxiety © CU Aging Center 2/2007 Unlikely 1 2 3 1 2 3 1 2 3 Almost Certain Unlikely 4 5 6 7 Medical Illness 1 2 3 4 5 6 7 Medication 1 2 3 4 5 6 7 Personality Problems 1 2 3 Almost Certain 4 5 6 7 4 5 6 7 4 5 6 7 CG IADL/ADL & Attributions Form (V1.2) 2 Geriatric Anxiety Scale (GAS) © Daniel L. Segal, Ph.D., 2014 Below is a list of common symptoms of anxiety or stress. Please read each item in the list carefully. Indicate how often you have experienced each symptom during the PAST WEEK, INCLUDING TODAY by checking under the corresponding answer. Not at all (0) 1. My heart raced or beat strongly. 2. My breath was short. 3. I had an upset stomach. 4. I felt like things were not real or like I was outside of myself. 5. I felt like I was losing control. 6. I was afraid of being judged by others. 7. I was afraid of being humiliated or embarrassed. 8. I had difficulty falling asleep. 9. I had difficulty staying asleep. 10. I was irritable. 11. I had outbursts of anger. 12. I had difficulty concentrating. 13. I was easily startled or upset. 14. I was less interested in doing something I typically enjoy. 15. I felt detached or isolated from others. 16. I felt like I was in a daze. 17. I had a hard time sitting still. 18. I worried too much. 19. I could not control my worry. 20. I felt restless, keyed up, or on edge. 21. I felt tired. 22. My muscles were tense. 23. I had back pain, neck pain, or muscle cramps. 24. I felt like I had no control over my life. 25. I felt like something terrible was going to happen to me. 26. I was concerned about my finances. 27. I was concerned about my health. 28. I was concerned about my children. 29. I was afraid of dying. 30. I was afraid of becoming a burden to my family or children. Sometimes (1) Most of the time (2) All of the time (3) Geriatric Depression Scale Name__________________________________ Date__________ Directions: Please answer all questions. Circle Yes or No 1. Are you basically satisfied with your life?.......................................................... YES NO 2. Have you dropped many of your activities and interests?................................... YES NO 3. Do you feel that your life is empty?.................................................................... YES NO 4. Do you often get bored?...................................................................................... YES NO 5. Are you hopeful about the future?....................................................................... YES NO 6. Are you bothered by thoughts you can’t get out of your head?........................... YES NO 7. Are you in good spirits most of the time?............................................................ YES NO 8. Are you afraid that something bad is going to happen to you?........................... YES NO 9. Do you feel happy most of the time?................................................................... YES NO 10. Do you often feel helpless?............................................................................... YES NO 11. Do you often get restless and fidgety?.............................................................. YES NO YES NO 13. Do you frequently worry about the future?....................................................... YES NO 14. Do you feel you have more problems with memory than most?....................... YES NO 15. Do you think it is wonderful to be alive now?.................................................. YES NO 16. Do you often feel downhearted and blue?.......................................................... YES NO 17. Do you feel pretty worthless the way you are now?.......................................... YES NO 18. Do you worry a lot about the past?.................................................................... YES NO 19. Do you find life very exciting?.......................................................................... YES NO 20. Is it hard for you to get started on new projects?................................................ YES NO 21. Do you feel full of energy?................................................................................. YES NO 22. Do you feel that your situation is hopeless?....................................................... YES NO 23. Do you think that most people are better off than you are?................................ YES NO 24. Do you frequently get upset over little things?.................................................. YES NO 25. Do you frequently feel like crying?................................................................... YES NO 26. Do you have trouble concentrating?.................................................................. YES NO 27. Do you enjoy getting up in the morning?............................................................YES NO 28. Do you prefer to avoid social gatherings?......................................................... YES NO 29. Is it easy for you to make decisions?................................................................. YES NO 30. Is your mind as clear as it used to be?............................................................... YES NO 12. Do you prefer to stay at home, rather than going out and doing new things? 15-164, O’Malley V1, 3/5/15 HealthCircle Aging Center 4863 North Nevada Avenue, Suite 321 Colorado Springs, CO 80918 office 719-255-8002 fax 719-255-8006 Attachment A CAREGIVER REACTION SCALE The following questions are designed to help us understand the types of difficulties you and your family face as caregivers. Each item is ranked on a 1 to 4 scale. 1 (not at all) 2 (somewhat) 3 (quite a bit) 4 (completely) Please respond to all items by checking () the appropriate box (A) Here are some thoughts and feelings that people sometimes have about themselves as caregivers. How much does each statement describe your thoughts about your caregiving. 1 2 3 4 1 2 3 4 3 4 Wish you were free to lead a life of your own Feel Trapped by your relative’s illness Wish you could just run away Feel stressed by your relative’s illness and needs (B) How much does each statement describe you: You are exhausted when you go to bed at night You have more to do than you can handle You don’t have time just for yourself You work hard as a caregiver but never seem to make any progress (C) Caregivers sometimes feel that they lose important things in life because of their relative’s illness. To what extent have you personally lost the following: 1 Being able to confide in your relative The person whom you used to know Having someone who really knew you well A chance to do some of the things you planned © CU Aging Center 2/2007 CG Reaction Scale (V1) 2 15-164, O’Malley V1, 3/5/15 Contact with other people A sense of who you are Lost an important part of yourself Each item is ranked on a 1 to 4 scale. 1 (not at all) 2 (somewhat) 3 (quite a bit) 4 (completely) (D) People can often learn things about themselves from taking care of a relative. How much do you: 1 2 3 4 1 2 3 4 Believe you’ve learned how to deal with this very difficult situation Feel that, all in all, you’re a good caregiver In general, feel competent as a caregiver Feel self-confident as a caregiver (E) Since becoming a caregiver, how much have you: Become more aware of your inner strengths Become more self-confident Grown as a person Learned to do things you didn’t do before (F) There are many different ways of coping with the stress of caregiving. How often do you: 1 2 3 4 2 3 4 Try to accept your relative as he/she is, not how you wish he/she could be Try to think about the present rather than the future Try to keep your sense of humor Spend time alone Eat Smoke Get some exercise Watch TV Read Take some medication to calm you down Drink some alcohol (G) Family members don’t always see eye-to-eye when it comes to dealing with a relative who is ill. How much disagreement have you had with anyone in your family about the following issues: 1 The seriousness of your relative’s memory problems © CU Aging Center 2/2007 CG Reaction Scale (V1) 15-164, O’Malley V1, 3/5/15 The need to watch out for your relative’s safety What things your relative is able to do for him/herself Whether your relative should be placed in a nursing home or assisted living Each item is ranked on a 1 to 4 scale. 1 (not at all) 2 (somewhat) 3 (quite a bit) 4 (completely) (H) How much disagreement have you had with people in your family because they: 1 2 3 4 3 4 3 4 Don’t spend enough time with your relative Don’t do their share in caring for your relative Don’t show enough respect for your relative Lack patience with your relative Don’t visit or telephone you enough Don’t give you enough help Don’t show enough appreciation for your work as a caregiver Give you unwanted advice (I) How much do you agree with the following statements about your present work situation 1 2 You have less energy for your work You have missed too many days You have been dissatisfied with the quality of your work You worry about your relative while you’re at work Phone calls about or from your relative interrupt your work (J) These questions ask about your household expenses and your standard of living. Compared with just before you began to take care of your relative how much would you agree, with the following statements: 1 2 Total household income has decreased Total monthly expenses have increased In general, family finances work out at the end of the month Adapted from Pearlin, et al. (1990) _______________________________________ Name of person completing form © CU Aging Center 2/2007 ________________________ Date CG Reaction Scale (V1) This page intentionally left blank