Put in writing what you can help with, what you can’t, and for how long, before care becomes an assumption.
For unpaid family and informal caregivers whose responsibilities are often assumed rather than agreed to, so a labor of love doesn’t become extraction.
A patient may name a preferred caregiver. Only the caregiver can agree to the work.
Nothing you enter leaves this device. There’s no submit button. You choose whether to print it, save it, or send it.
Share it with the people who plan care: a discharge planner, case manager, social worker, the patient’s doctors, or your family. Bring it to a care conference or a meeting with a social worker. It works best as the start of a conversation, not a replacement for one. Afterward, sending it in writing creates a record of what was discussed.
Everything you enter stays on this device. Nothing is sent anywhere unless you send it. Your answers are saved in this browser so you can come back to them. On a shared or hospital computer, download your record when you’re done, then use Start over to clear it.
This record doesn’t renew on its own.
Answer the tasks the care plan expects from you. Anything you leave unanswered will appear on your record as “Not selected, so not offered.” You can also mark a task “Doesn’t apply.”
Being open to helping with a task isn’t a promise of unlimited availability. Travel, waiting, phone calls, and portal work count toward these limits.
Anything you declined or haven’t been trained for still needs a plan. Arranging that plan is the care team’s job, not something that falls back on you by default.
These are roles for others to confirm, not yours. If you don’t know, leave them blank, and the record will ask the care team or family to name someone.
This is the record the care team will see. Download or print it, then send the email below with it attached. Using someone else’s device? Download your record, then choose Start over so your answers aren’t left behind.
If setting limits could put your housing, finances, or safety at risk, think carefully about timing and about who sees this record. A social worker or a caregiver support organization can help you plan how and when to share it.
Sending this creates a dated record that your limits were sent. Ask the team to confirm they received it, and to add it to the patient’s chart. Many hospitals prefer messages through the patient portal, so you can paste it there instead. For long records, use Copy email rather than Open in email app, since some email apps cut long links short.