Caregiver Assessment Form — shared by the community
Marta K. shared this 14-question build with 2 conditional rules already wired up. Test it below, then take a copy.
A ready-to-use healthcare & clinical form for small teams who need a reliable intake process: 14 questions, 2 pages, 2 conditional rules.
- Shared by
- Marta K. · Practice manager
- Questions
- 14
- Replies
- 21
- Copies taken
- 542
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Live preview and test console
This is the real form. Answer it to test the 2 conditional rules — nothing is sent or stored.
Page 1 of 2 — About you and your caregiving role
1 question is hidden by conditional logic right now — change an answer above to reveal it.
Works for you? Take Marta K.'s copy into your own workspace — questions, rules and settings included.
Who this template is for
Caregiver Assessment Form is built for small teams who need a reliable intake process who need to collect the same complete information from everyone.
- Small teams who need a reliable intake process working in healthcare & clinical.
- Teams who need to collect the same complete information from everyone without writing code or paying for a custom build.
- Anyone replacing chasing missing details over email with one structured record per enquiry.
- Respondents are the people you send it to — the form asks them 14 questions across 2 screens.
- Mobile-heavy audiences, thanks to the one-question-per-screen card layout.
Why this form is useful
It removes the cost of chasing missing details over email and turns each submission into a record your team can act on immediately.
- 10 questions are required, so submissions arrive complete instead of needing a follow-up email.
- It collects a verified email address so replies and confirmations land.
- It captures a phone number for urgent follow-up.
- It allows multiple selections without free text.
- It captures a numeric value you can filter and sort on.
- Conditional logic hides 2 questions until they are relevant — shorter forms convert better than long ones.
- Splitting the form across 2 pages keeps each screen short and shows respondents how much is left.
- Every response is stored, searchable and exportable, so nothing depends on one person's inbox.
How to use this template
From copy to live form is a few minutes of work, and every step is reversible.
- 1Press “Use this template” — a fresh copy of Caregiver Assessment Form lands in your workspace, ready to edit.
- 2Rename or delete any question, and change what is required. Nothing here is fixed.
- 3Open Notifications and add the email addresses that should be alerted on each submission; add an auto-reply to the respondent if the form collects an email address.
- 4Publish it, then either share the link directly or paste the embed snippet into your site — the embedded form resizes to fit and loads no marketing or advertising trackers.
- 5Watch responses land in Submissions, where you can filter, label and export them to CSV or PDF.
Logic and conditions blueprint
Exactly how this form behaves as it is answered — 2 conditional rules ship with it.
- Features advanced show logic: if “Do you have help from anyone else with caregiving?” is Yes, the form dynamically exposes “Who else helps?”. Otherwise that question never appears.
- Features advanced show logic: if “Has caregiving affected your own health or work?” is Yes, the form dynamically exposes “Describe how it has affected you”. Otherwise that question never appears.
- All 2 rules are editable in the Logic tab, and the built-in checker warns about rules that contradict each other.
What this form asks
Page 1 — About you and your caregiving role
- Caregiver full namerequired
- Phone numberrequired
- Email addressrequired
- Name of the person you care forrequired
- Relationship to the person you care forrequired
- Hours per week spent caregivingrequired
- Main caregiving tasks you providerequired
- Do you have help from anyone else with caregiving?required
- Who else helps?
Page 2 — Your wellbeing and support needs
- Do you feel you have enough support to continue caregiving?required
- What kind of support would help you most?
- Has caregiving affected your own health or work?required
- Describe how it has affected you
- Services you would like more information about
Conditional logic in this build
- When “Do you have help from anyone else with caregiving?” is Yes, show “Who else helps?”.
- When “Has caregiving affected your own health or work?” is Yes, show “Describe how it has affected you”.
Questions about this shared form
Does this assess the care recipient's needs?
No. It is built entirely around the caregiver's own hours, tasks and wellbeing; a separate assessment covers the person receiving care.
Can more than one caregiver complete this for the same person?
Yes, and it is often useful, since two caregivers sharing a role can have very different levels of strain and support.
What if the caregiver does not want any services right now?
Leave the services question unanswered or select none; the rest of the assessment still gives the agency a useful record for later.
How often should this be repeated?
A caregiver's situation can change quickly, so many agencies repeat it every few months or whenever a caregiver's circumstances shift.
Is the Caregiver Assessment Form template free to use?
Yes. You can preview and test Caregiver Assessment Form on this page without an account, and take a copy into your own HelloForms workspace on the free plan. There is nothing to install and no card required to publish it.
What does the Caregiver Assessment Form template ask for?
It asks 14 questions across 2 pages, 10 of which are required. Every question is listed in full further down this page, and each one can be renamed, reordered, made optional or deleted after you copy the template.
Can I edit the Caregiver Assessment Form form after copying it?
Yes — the copy is entirely yours. Change wording, add or remove questions, switch between the classic and card layouts, restyle it to match your brand, and set who gets notified on each submission.
How does the conditional logic in this healthcare & clinical form work?
2 conditional rules ship with the template: Features advanced show logic: if “Do you have help from anyone else with caregiving?” is Yes, the form dynamically exposes “Who else helps?”. Otherwise that question never appears. Features advanced show logic: if “Has caregiving affected your own health or work?” is Yes, the form dynamically exposes “Describe how it has affected you”. Otherwise that question never appears. All 2 rules are editable in the Logic tab, and the built-in checker warns about rules that contradict each other. All rules are editable in the Logic tab.
Where do responses to the Caregiver Assessment Form form go?
Submissions land in your workspace under Submissions, where you can search, filter, label and export them to CSV or PDF. You can also email a notification to your team on every submission and send the respondent an auto-reply.
Can I embed the Caregiver Assessment Form form on my own website?
Yes. Publish the form and paste the embed snippet into any page or share the direct link. The embedded form resizes to fit its container and loads no advertising or marketing trackers inside the iframe.
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