Alexis Olson PhD
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Client Portal
About Me
Goals
Assessment
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Books
Care Questionnaire
Rates
Contact
Cart
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Alexis Olson PhD
Client Portal
About Me
Goals
Assessment
Tools
Books
Care Questionnaire
Rates
Contact
Caregiver Questionnaire
Name
*
First Name
Last Name
Email
*
Phone
(###)
###
####
Your Caregiving Role
*
Research Consent
Yes, contribute my results to research efforts on caregiving!
Your Note to Dr. Olson
CGQ_FEEDBACK
Details for Research Efforts
Caregiving Duration
*
How long have you been caregiving?
Anticipate caregiving in the future
<1 month of caregiving
1 to 6 months of caregiving
7 to 12 months of caregiving
1 to 2 years of caregiving
>2 years of caregiving
Gender
*
Female
Male
Non-binary
Ethnicity
*
Asian
African American
Latino
Native American
Other Pacific Islander
White
Multi-ethnic
Other
Education
*
Less than high school
High school diploma or GED
Some college
Associate degree
Bachelor's degree
Master's degree
Doctorate or professional degree (PhD, MD, JD, etc.)
Employment Status
*
Employed full-time
Employed part-time
Self-employed
Professional caregiver
Unemployed and looking for work
Unemployed and not looking for work
Retired
Student
Other
Income Level Annually
*
Less than $20,000
$20,000 to $59,999
$60,000 to $100,000
Over $100,000
Relationship Status
*
Single, never married
Married or domestic partnership
Divorced
Widowed
Separated
Prefer not to say
Household Size
*
How many people (including yourself) live in the home you sleep in
1 person
2 people
3 people
4 people
5 or more people
What state/country do you live in?
*
Religion/Spirituality
*
Not spiritual/religious
Actively attend place religious/spiritual gathering
Actively practicing, without attending a gathering
Agnostic
Other
Your message and results are on their way to Dr. Olson! She will reach out to you shortly.