{"id":5139,"date":"2024-01-29T14:05:37","date_gmt":"2024-01-29T19:05:37","guid":{"rendered":"https:\/\/atlasseniorliving.com\/madison-range\/?page_id=5139"},"modified":"2025-09-23T15:05:18","modified_gmt":"2025-09-23T20:05:18","slug":"caregiver-form","status":"publish","type":"page","link":"https:\/\/atlasseniorliving.com\/madison-range\/caregiver-form\/","title":{"rendered":"Caregiver Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"5139\" class=\"elementor elementor-5139\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-68d4237 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"68d4237\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-b76eebf\" data-id=\"b76eebf\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-7d2c1cc elementor-hidden-mobile elementor-widget elementor-widget-heading\" data-id=\"7d2c1cc\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Caregiver Burnout Assessment<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-84f53d9 elementor-reverse-mobile elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"84f53d9\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-0b41af8\" data-id=\"0b41af8\" data-element_type=\"column\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-93ff837 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"93ff837\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-inner-column elementor-element elementor-element-8daa766\" data-id=\"8daa766\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-0dfe8eb elementor-widget elementor-widget-image\" data-id=\"0dfe8eb\" data-element_type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img fetchpriority=\"high\" decoding=\"async\" width=\"969\" height=\"440\" src=\"https:\/\/atlasseniorliving.com\/madison-range\/wp-content\/uploads\/sites\/22\/2024\/01\/caregiver-form-head.jpg\" class=\"attachment-full size-full wp-image-5146\" alt=\"Exploring the Depths of Caregiver Emotions Madison at the range\" srcset=\"https:\/\/atlasseniorliving.com\/madison-range\/wp-content\/uploads\/sites\/22\/2024\/01\/caregiver-form-head.jpg 969w, https:\/\/atlasseniorliving.com\/madison-range\/wp-content\/uploads\/sites\/22\/2024\/01\/caregiver-form-head-300x136.jpg 300w, https:\/\/atlasseniorliving.com\/madison-range\/wp-content\/uploads\/sites\/22\/2024\/01\/caregiver-form-head-768x349.jpg 768w\" sizes=\"(max-width: 969px) 100vw, 969px\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<div class=\"elementor-element elementor-element-ea03c6a uael-wpf-input-size-lg uael-wpf-check-yes uael-wpf-btn-size-lg uael-wpf-button-center uael-wpf-style-box uael-wpf-highlight-style-default elementor-widget elementor-widget-uael-wpf-styler\" data-id=\"ea03c6a\" data-element_type=\"widget\" data-settings=\"{&quot;wpf_input_padding&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;top&quot;:&quot;10&quot;,&quot;right&quot;:&quot;10&quot;,&quot;bottom&quot;:&quot;10&quot;,&quot;left&quot;:&quot;10&quot;,&quot;isLinked&quot;:true},&quot;wpf_button_padding&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;top&quot;:&quot;10&quot;,&quot;right&quot;:&quot;40&quot;,&quot;bottom&quot;:&quot;10&quot;,&quot;left&quot;:&quot;40&quot;,&quot;isLinked&quot;:false},&quot;btn_border_radius&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;top&quot;:&quot;0&quot;,&quot;right&quot;:&quot;0&quot;,&quot;bottom&quot;:&quot;0&quot;,&quot;left&quot;:&quot;0&quot;,&quot;isLinked&quot;:true},&quot;form_fields_margin&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:0,&quot;sizes&quot;:[]},&quot;form_label_margin_bottom&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:5,&quot;sizes&quot;:[]},&quot;form_desc_margin_top&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:5,&quot;sizes&quot;:[]},&quot;submit_spacing&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:0,&quot;sizes&quot;:[]},&quot;wpf_button_align&quot;:&quot;center&quot;,&quot;wpf_input_padding_tablet&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;top&quot;:&quot;&quot;,&quot;right&quot;:&quot;&quot;,&quot;bottom&quot;:&quot;&quot;,&quot;left&quot;:&quot;&quot;,&quot;isLinked&quot;:true},&quot;wpf_input_padding_mobile&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;top&quot;:&quot;&quot;,&quot;right&quot;:&quot;&quot;,&quot;bottom&quot;:&quot;&quot;,&quot;left&quot;:&quot;&quot;,&quot;isLinked&quot;:true},&quot;wpf_input_radius&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;top&quot;:&quot;0&quot;,&quot;right&quot;:&quot;0&quot;,&quot;bottom&quot;:&quot;0&quot;,&quot;left&quot;:&quot;0&quot;,&quot;isLinked&quot;:true},&quot;wpf_input_radius_tablet&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;top&quot;:&quot;&quot;,&quot;right&quot;:&quot;&quot;,&quot;bottom&quot;:&quot;&quot;,&quot;left&quot;:&quot;&quot;,&quot;isLinked&quot;:true},&quot;wpf_input_radius_mobile&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;top&quot;:&quot;&quot;,&quot;right&quot;:&quot;&quot;,&quot;bottom&quot;:&quot;&quot;,&quot;left&quot;:&quot;&quot;,&quot;isLinked&quot;:true},&quot;wpf_button_padding_tablet&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;top&quot;:&quot;&quot;,&quot;right&quot;:&quot;&quot;,&quot;bottom&quot;:&quot;&quot;,&quot;left&quot;:&quot;&quot;,&quot;isLinked&quot;:true},&quot;wpf_button_padding_mobile&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;top&quot;:&quot;&quot;,&quot;right&quot;:&quot;&quot;,&quot;bottom&quot;:&quot;&quot;,&quot;left&quot;:&quot;&quot;,&quot;isLinked&quot;:true},&quot;btn_border_radius_tablet&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;top&quot;:&quot;&quot;,&quot;right&quot;:&quot;&quot;,&quot;bottom&quot;:&quot;&quot;,&quot;left&quot;:&quot;&quot;,&quot;isLinked&quot;:true},&quot;btn_border_radius_mobile&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;top&quot;:&quot;&quot;,&quot;right&quot;:&quot;&quot;,&quot;bottom&quot;:&quot;&quot;,&quot;left&quot;:&quot;&quot;,&quot;isLinked&quot;:true},&quot;form_fields_margin_tablet&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;form_fields_margin_mobile&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;form_label_margin_bottom_tablet&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;form_label_margin_bottom_mobile&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;form_desc_margin_top_tablet&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;form_desc_margin_top_mobile&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;check_radio_items_spacing&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;check_radio_items_spacing_tablet&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;check_radio_items_spacing_mobile&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;submit_spacing_tablet&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;submit_spacing_mobile&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]}}\" data-widget_type=\"uael-wpf-styler.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class = \"uael-wpf-container\">\n\t\t\t\t\t\t<div class = \"uael-wpf uael-wpf-style elementor-clickable\">\n\t\t\t\t\t\t<div class=\"wpforms-container wpforms-container-full\" id=\"wpforms-5097\"><form id=\"wpforms-form-5097\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"5097\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/madison-range\/wp-json\/wp\/v2\/pages\/5139\" data-token=\"536b22e2ea203cb5a7f42061ff2143ef\" data-token-time=\"1776288846\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-page-indicator progress\" data-indicator=\"progress\" data-indicator-color=\"#72b239\" data-scroll=\"1\"><span class=\"wpforms-page-indicator-page-title\" ><\/span><span class=\"wpforms-page-indicator-page-title-sep\" style=\"display:none;\"> - <\/span><span class=\"wpforms-page-indicator-steps\">Step <span class=\"wpforms-page-indicator-steps-current\">1<\/span> of 2<\/span><div class=\"wpforms-page-indicator-page-progress-wrap\"><div class=\"wpforms-page-indicator-page-progress\" style=\"width:50%;background-color:#72b239\"><\/div><\/div><\/div><div class=\"wpforms-field-container\"><div class=\"wpforms-page wpforms-page-1 \" data-page=\"1\"><div id=\"wpforms-5097-field_33-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"33\"><\/div><div id=\"wpforms-5097-field_38-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"38\"><div id=\"wpforms-5097-field_38\"><h1 style=\"font-size:20px\">Please Enter your Data to Start our Quiz<\/h1><\/div><\/div><div id=\"wpforms-5097-field_26-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"26\"><label class=\"wpforms-field-label\" for=\"wpforms-5097-field_26\">Name <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-5097-field_26\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][26]\" required><\/div><div id=\"wpforms-5097-field_27-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"27\"><label class=\"wpforms-field-label\" for=\"wpforms-5097-field_27\">Email <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-5097-field_27\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][27]\" spellcheck=\"false\" required><\/div><div id=\"wpforms-5097-field_39-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"39\"><label class=\"wpforms-field-label\" for=\"wpforms-5097-field_39\">Phone<\/label><input type=\"tel\" id=\"wpforms-5097-field_39\" class=\"wpforms-field-large wpforms-masked-input\" data-inputmask=\"&#039;mask&#039;: &#039;(999) 999-9999&#039;\" data-rule-us-phone-field=\"true\" data-inputmask-inputmode=\"tel\" name=\"wpforms[fields][39]\" aria-label=\"Phone\" ><\/div><div id=\"wpforms-5097-field_32-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"32\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"1\" data-formid=\"5097\" disabled>Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-2 last \" data-page=\"2\" style=\"display:none;\"><div id=\"wpforms-5097-field_15-container\" class=\"wpforms-field wpforms-field-payment-multiple wpforms-list-inline\" data-field-id=\"15\"><label class=\"wpforms-field-label\">How often do you find yourself suppressing your emotions to stay strong for the person you are caring for? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-5097-field_15\" class=\"wpforms-field-required\"><li class=\"choice-1\"><input type=\"radio\" id=\"wpforms-5097-field_15_1\" class=\"wpforms-payment-price\" data-amount=\"1.00\" name=\"wpforms[fields][15]\" value=\"1\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5097-field_15_1\">Rarely or never<\/label><\/li><li class=\"choice-2\"><input type=\"radio\" id=\"wpforms-5097-field_15_2\" class=\"wpforms-payment-price\" data-amount=\"2.00\" name=\"wpforms[fields][15]\" value=\"2\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5097-field_15_2\">Occasionally<\/label><\/li><li class=\"choice-3\"><input type=\"radio\" id=\"wpforms-5097-field_15_3\" class=\"wpforms-payment-price\" data-amount=\"3.00\" name=\"wpforms[fields][15]\" value=\"3\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5097-field_15_3\">Frequently<\/label><\/li><li class=\"choice-4\"><input type=\"radio\" id=\"wpforms-5097-field_15_4\" class=\"wpforms-payment-price\" data-amount=\"4.00\" name=\"wpforms[fields][15]\" value=\"4\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5097-field_15_4\">Almost always<\/label><\/li><\/ul><\/div><div id=\"wpforms-5097-field_17-container\" class=\"wpforms-field wpforms-field-payment-multiple wpforms-list-inline\" data-field-id=\"17\"><label class=\"wpforms-field-label\">In the past month, have you noticed a significant change in your ability to concentrate on tasks unrelated to caregiving? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-5097-field_17\" class=\"wpforms-field-required\"><li class=\"choice-1\"><input type=\"radio\" id=\"wpforms-5097-field_17_1\" class=\"wpforms-payment-price\" data-amount=\"1.00\" name=\"wpforms[fields][17]\" value=\"1\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5097-field_17_1\">No change<\/label><\/li><li class=\"choice-2\"><input type=\"radio\" id=\"wpforms-5097-field_17_2\" class=\"wpforms-payment-price\" data-amount=\"2.00\" name=\"wpforms[fields][17]\" value=\"2\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5097-field_17_2\">Slight change<\/label><\/li><li class=\"choice-3\"><input type=\"radio\" id=\"wpforms-5097-field_17_3\" class=\"wpforms-payment-price\" data-amount=\"3.00\" name=\"wpforms[fields][17]\" value=\"3\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5097-field_17_3\">Noticeable change<\/label><\/li><li class=\"choice-4\"><input type=\"radio\" id=\"wpforms-5097-field_17_4\" class=\"wpforms-payment-price\" data-amount=\"4.00\" name=\"wpforms[fields][17]\" value=\"4\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5097-field_17_4\">Significant change<\/label><\/li><\/ul><\/div><div id=\"wpforms-5097-field_19-container\" class=\"wpforms-field wpforms-field-payment-multiple wpforms-list-inline\" data-field-id=\"19\"><label class=\"wpforms-field-label\">To what extent do you feel a sense of isolation or loneliness in your role as a caregiver? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-5097-field_19\" class=\"wpforms-field-required\"><li class=\"choice-1\"><input type=\"radio\" id=\"wpforms-5097-field_19_1\" class=\"wpforms-payment-price\" data-amount=\"1.00\" name=\"wpforms[fields][19]\" value=\"1\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5097-field_19_1\">Not at all<\/label><\/li><li class=\"choice-2\"><input type=\"radio\" id=\"wpforms-5097-field_19_2\" class=\"wpforms-payment-price\" data-amount=\"2.00\" name=\"wpforms[fields][19]\" value=\"2\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5097-field_19_2\">A little<\/label><\/li><li class=\"choice-3\"><input type=\"radio\" id=\"wpforms-5097-field_19_3\" class=\"wpforms-payment-price\" data-amount=\"3.00\" name=\"wpforms[fields][19]\" value=\"3\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5097-field_19_3\">Moderately<\/label><\/li><li class=\"choice-4\"><input type=\"radio\" id=\"wpforms-5097-field_19_4\" class=\"wpforms-payment-price\" data-amount=\"4.00\" name=\"wpforms[fields][19]\" value=\"4\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5097-field_19_4\">Extremely<\/label><\/li><\/ul><\/div><div id=\"wpforms-5097-field_16-container\" class=\"wpforms-field wpforms-field-payment-multiple wpforms-list-inline\" data-field-id=\"16\"><label class=\"wpforms-field-label\">How often do you experience guilt or self-blame related to your caregiving responsibilities? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-5097-field_16\" class=\"wpforms-field-required\"><li class=\"choice-1\"><input type=\"radio\" id=\"wpforms-5097-field_16_1\" class=\"wpforms-payment-price\" data-amount=\"1.00\" name=\"wpforms[fields][16]\" value=\"1\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5097-field_16_1\">Rarely or never<\/label><\/li><li class=\"choice-2\"><input type=\"radio\" id=\"wpforms-5097-field_16_2\" class=\"wpforms-payment-price\" data-amount=\"2.00\" name=\"wpforms[fields][16]\" value=\"2\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5097-field_16_2\">Occasionally<\/label><\/li><li class=\"choice-3\"><input type=\"radio\" id=\"wpforms-5097-field_16_3\" class=\"wpforms-payment-price\" data-amount=\"3.00\" name=\"wpforms[fields][16]\" value=\"3\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5097-field_16_3\">Frequently<\/label><\/li><li class=\"choice-4\"><input type=\"radio\" id=\"wpforms-5097-field_16_4\" class=\"wpforms-payment-price\" data-amount=\"4.00\" name=\"wpforms[fields][16]\" value=\"4\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5097-field_16_4\">Almost always<\/label><\/li><\/ul><\/div><div id=\"wpforms-5097-field_20-container\" class=\"wpforms-field wpforms-field-payment-multiple wpforms-list-inline\" data-field-id=\"20\"><label class=\"wpforms-field-label\">Have you noticed any changes in your physical health, such as headaches or stomach issues, since taking on caregiving duties? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-5097-field_20\" class=\"wpforms-field-required\"><li class=\"choice-1\"><input type=\"radio\" id=\"wpforms-5097-field_20_1\" class=\"wpforms-payment-price\" data-amount=\"1.00\" name=\"wpforms[fields][20]\" value=\"1\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5097-field_20_1\">No changes<\/label><\/li><li class=\"choice-2\"><input type=\"radio\" id=\"wpforms-5097-field_20_2\" class=\"wpforms-payment-price\" data-amount=\"2.00\" name=\"wpforms[fields][20]\" value=\"2\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5097-field_20_2\">Slight changes<\/label><\/li><li class=\"choice-3\"><input type=\"radio\" id=\"wpforms-5097-field_20_3\" class=\"wpforms-payment-price\" data-amount=\"3.00\" name=\"wpforms[fields][20]\" value=\"3\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5097-field_20_3\">Moderate changes<\/label><\/li><li class=\"choice-4\"><input type=\"radio\" id=\"wpforms-5097-field_20_4\" class=\"wpforms-payment-price\" data-amount=\"4.00\" name=\"wpforms[fields][20]\" value=\"4\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5097-field_20_4\">Significant changes<\/label><\/li><\/ul><\/div><div id=\"wpforms-5097-field_21-container\" class=\"wpforms-field wpforms-field-payment-multiple wpforms-list-inline\" data-field-id=\"21\"><label class=\"wpforms-field-label\">In the past two weeks, how often have you felt overwhelmed by the tasks and responsibilities associated with caregiving? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-5097-field_21\" class=\"wpforms-field-required\"><li class=\"choice-1\"><input type=\"radio\" id=\"wpforms-5097-field_21_1\" class=\"wpforms-payment-price\" data-amount=\"1.00\" name=\"wpforms[fields][21]\" value=\"1\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5097-field_21_1\">Never<\/label><\/li><li class=\"choice-2\"><input type=\"radio\" id=\"wpforms-5097-field_21_2\" class=\"wpforms-payment-price\" data-amount=\"2.00\" name=\"wpforms[fields][21]\" value=\"2\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5097-field_21_2\">Rarely<\/label><\/li><li class=\"choice-3\"><input type=\"radio\" id=\"wpforms-5097-field_21_3\" class=\"wpforms-payment-price\" data-amount=\"3.00\" name=\"wpforms[fields][21]\" value=\"3\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5097-field_21_3\">Occasionally<\/label><\/li><li class=\"choice-4\"><input type=\"radio\" id=\"wpforms-5097-field_21_4\" class=\"wpforms-payment-price\" data-amount=\"4.00\" name=\"wpforms[fields][21]\" value=\"4\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5097-field_21_4\">Frequently<\/label><\/li><\/ul><\/div><div id=\"wpforms-5097-field_22-container\" class=\"wpforms-field wpforms-field-payment-multiple wpforms-list-inline\" data-field-id=\"22\"><label class=\"wpforms-field-label\">Do you feel that your own needs and well-being are often neglected due to your caregiving responsibilities? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-5097-field_22\" class=\"wpforms-field-required\"><li class=\"choice-1\"><input type=\"radio\" id=\"wpforms-5097-field_22_1\" class=\"wpforms-payment-price\" data-amount=\"1.00\" name=\"wpforms[fields][22]\" value=\"1\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5097-field_22_1\">Not at all<\/label><\/li><li class=\"choice-2\"><input type=\"radio\" id=\"wpforms-5097-field_22_2\" class=\"wpforms-payment-price\" data-amount=\"2.00\" name=\"wpforms[fields][22]\" value=\"2\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5097-field_22_2\">A little<\/label><\/li><li class=\"choice-3\"><input type=\"radio\" id=\"wpforms-5097-field_22_3\" class=\"wpforms-payment-price\" data-amount=\"3.00\" name=\"wpforms[fields][22]\" value=\"3\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5097-field_22_3\">Moderately<\/label><\/li><li class=\"choice-4\"><input type=\"radio\" id=\"wpforms-5097-field_22_4\" class=\"wpforms-payment-price\" data-amount=\"4.00\" name=\"wpforms[fields][22]\" value=\"4\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5097-field_22_4\">Completely<\/label><\/li><\/ul><\/div><div id=\"wpforms-5097-field_23-container\" class=\"wpforms-field wpforms-field-payment-multiple wpforms-list-inline\" data-field-id=\"23\"><label class=\"wpforms-field-label\">How satisfied are you with the support you receive from friends and family in your role as a caregiver? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-5097-field_23\" class=\"wpforms-field-required\"><li class=\"choice-1\"><input type=\"radio\" id=\"wpforms-5097-field_23_1\" class=\"wpforms-payment-price\" data-amount=\"1.00\" name=\"wpforms[fields][23]\" value=\"1\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5097-field_23_1\">Very satisfied<\/label><\/li><li class=\"choice-2\"><input type=\"radio\" id=\"wpforms-5097-field_23_2\" class=\"wpforms-payment-price\" data-amount=\"2.00\" name=\"wpforms[fields][23]\" value=\"2\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5097-field_23_2\">Somewhat satisfied<\/label><\/li><li class=\"choice-3\"><input type=\"radio\" id=\"wpforms-5097-field_23_3\" class=\"wpforms-payment-price\" data-amount=\"3.00\" name=\"wpforms[fields][23]\" value=\"3\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5097-field_23_3\">Neutral<\/label><\/li><li class=\"choice-4\"><input type=\"radio\" id=\"wpforms-5097-field_23_4\" class=\"wpforms-payment-price\" data-amount=\"4.00\" name=\"wpforms[fields][23]\" value=\"4\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5097-field_23_4\">Dissatisfied<\/label><\/li><\/ul><\/div><div id=\"wpforms-5097-field_24-container\" class=\"wpforms-field wpforms-field-payment-multiple wpforms-list-inline\" data-field-id=\"24\"><label class=\"wpforms-field-label\">To what extent do you feel that your personal and professional life has been affected by your caregiving responsibilities? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-5097-field_24\" class=\"wpforms-field-required\"><li class=\"choice-1\"><input type=\"radio\" id=\"wpforms-5097-field_24_1\" class=\"wpforms-payment-price\" data-amount=\"1.00\" name=\"wpforms[fields][24]\" value=\"1\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5097-field_24_1\">Not at all<\/label><\/li><li class=\"choice-2\"><input type=\"radio\" id=\"wpforms-5097-field_24_2\" class=\"wpforms-payment-price\" data-amount=\"2.00\" name=\"wpforms[fields][24]\" value=\"2\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5097-field_24_2\">Slightly<\/label><\/li><li class=\"choice-3\"><input type=\"radio\" id=\"wpforms-5097-field_24_3\" class=\"wpforms-payment-price\" data-amount=\"3.00\" name=\"wpforms[fields][24]\" value=\"3\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5097-field_24_3\">Moderately<\/label><\/li><li class=\"choice-4\"><input type=\"radio\" id=\"wpforms-5097-field_24_4\" class=\"wpforms-payment-price\" data-amount=\"4.00\" name=\"wpforms[fields][24]\" value=\"4\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5097-field_24_4\">Significantly<\/label><\/li><\/ul><\/div><div id=\"wpforms-5097-field_25-container\" class=\"wpforms-field wpforms-field-payment-multiple wpforms-list-inline\" data-field-id=\"25\"><label class=\"wpforms-field-label\">In the past month, have you experienced a significant decrease in your interest or enjoyment in activities that you used to find pleasurable? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-5097-field_25\" class=\"wpforms-field-required\"><li class=\"choice-1\"><input type=\"radio\" id=\"wpforms-5097-field_25_1\" class=\"wpforms-payment-price\" data-amount=\"1.00\" name=\"wpforms[fields][25]\" value=\"1\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5097-field_25_1\">Not at all<\/label><\/li><li class=\"choice-2\"><input type=\"radio\" id=\"wpforms-5097-field_25_2\" class=\"wpforms-payment-price\" data-amount=\"2.00\" name=\"wpforms[fields][25]\" value=\"2\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5097-field_25_2\">A little<\/label><\/li><li class=\"choice-3\"><input type=\"radio\" id=\"wpforms-5097-field_25_3\" class=\"wpforms-payment-price\" data-amount=\"3.00\" name=\"wpforms[fields][25]\" value=\"3\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5097-field_25_3\">Moderately<\/label><\/li><li class=\"choice-4\"><input type=\"radio\" id=\"wpforms-5097-field_25_4\" class=\"wpforms-payment-price\" data-amount=\"4.00\" name=\"wpforms[fields][25]\" value=\"4\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-5097-field_25_4\">Very much<\/label><\/li><\/ul><\/div><div id=\"wpforms-5097-field_18-container\" class=\"wpforms-field wpforms-field-payment-total hide-field wpforms-field-medium\" data-field-id=\"18\"><label class=\"wpforms-field-label\">Total Points<\/label><div class=\"wpforms-payment-total\" style=\"\">&#036;0.00<\/div><input type=\"hidden\" id=\"wpforms-5097-field_18\" class=\"wpforms-field-medium wpforms-payment-total\" name=\"wpforms[fields][18]\" value=\"0\"><\/div><div id=\"wpforms-5097-field_40-container\" class=\"wpforms-field wpforms-field-hidden\" data-field-id=\"40\"><input type=\"hidden\" id=\"wpforms-5097-field_40\" name=\"wpforms[fields][40]\"><\/div><div id=\"wpforms-5097-field_41-container\" class=\"wpforms-field wpforms-field-hidden\" data-field-id=\"41\"><input type=\"hidden\" id=\"wpforms-5097-field_41\" name=\"wpforms[fields][41]\"><\/div><div id=\"wpforms-5097-field_34-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"34\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><\/div><\/div><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" style=\"display:none;\"><input type=\"hidden\" name=\"wpforms[id]\" value=\"5097\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/atlasseniorliving.com\/madison-range\/wp-json\/wp\/v2\/pages\/5139\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-5097\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img decoding=\"async\" src=\"https:\/\/atlasseniorliving.com\/madison-range\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Caregiver Burnout Assessment Please enable JavaScript in your browser to complete this form.How often do you find yourself suppressing your emotions to stay strong for the person you are caring for? * Rarely or never Occasionally Frequently Almost always In the past month, have you noticed a significant change in your ability to concentrate on [&hellip;]<\/p>\n","protected":false},"author":36,"featured_media":5146,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"site-sidebar-layout":"no-sidebar","site-content-layout":"page-builder","ast-site-content-layout":"full-width-container","site-content-style":"unboxed","site-sidebar-style":"unboxed","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"disabled","ast-breadcrumbs-content":"","ast-featured-img":"disabled","footer-sml-layout":"","theme-transparent-header-meta":"default","adv-header-id-meta":"","stick-header-meta":"default","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"set","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center 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