Step 4
Create your self-care plan
Now that you’ve identified your priority pain points, take some time to visualize your goals and set a self-care plan in place that will help you cope with and/or overcome the issues that are causing you the most stress.
Pain point
Are you having feelings of being overwhelmed, overworked, and/or overburdened?
Describe what you would like to change to improve this aspect of caregiving.
Describe immediate steps that you can take to help improve this aspect of caregiving.
Describe the type of support and resources you will need to make this change.
Pain point
Has there been a change in your relationship with your spouse/relative?
Describe what you would like to change to improve this aspect of caregiving.
Describe immediate steps that you can take to help improve this aspect of caregiving.
Describe the type of support and resources you will need to make this change.
Pain point
Have you noticed any changes in your social life?
Describe what you would like to change to improve this aspect of caregiving.
Describe immediate steps that you can take to help improve this aspect of caregiving.
Describe the type of support and resources you will need to make this change.
Pain point
Are you having any conflicts with your previous daily commitments? (e.g., work/volunteering)
Describe what you would like to change to improve this aspect of caregiving.
Describe immediate steps that you can take to help improve this aspect of caregiving.
Describe the type of support and resources you will need to make this change.
Pain point
Do you have feelings of being confined or trapped by the responsibilities or demands of caregiving?
Describe what you would like to change to improve this aspect of caregiving.
Describe immediate steps that you can take to help improve this aspect of caregiving.
Describe the type of support and resources you will need to make this change.
Pain point
Do you ever have feelings related to a lack of confidence in your ability to provide care?
Describe what you would like to change to improve this aspect of caregiving.
Describe immediate steps that you can take to help improve this aspect of caregiving.
Describe the type of support and resources you will need to make this change.
Pain point
Do you have concerns regarding the future care needs of your spouse/relative?
Describe what you would like to change to improve this aspect of caregiving.
Describe immediate steps that you can take to help improve this aspect of caregiving.
Describe the type of support and resources you will need to make this change.
Pain point
Are you having any conflicts within your family over care decisions?
Describe what you would like to change to improve this aspect of caregiving.
Describe immediate steps that you can take to help improve this aspect of caregiving.
Describe the type of support and resources you will need to make this change.
Pain point
Are you having any conflicts within your family over the amount of support you are receiving in providing care?
Describe what you would like to change to improve this aspect of caregiving.
Describe immediate steps that you can take to help improve this aspect of caregiving.
Describe the type of support and resources you will need to make this change.
Pain point
Are you having any financial difficulties associated with caregiving?
Describe what you would like to change to improve this aspect of caregiving.
Describe immediate steps that you can take to help improve this aspect of caregiving.
Describe the type of support and resources you will need to make this change.
Keep this self-care plan as it will be useful for future comparison to measure change and improvement.
You didn't select any priorities in step 3, please go back and select your pain points.
Caregiver Self-Care Plan
Downloaded from CaregiverSelfCarePlan.ca
Date: October 23, 2024
Kingston Caregiver Stress Scale (KCSS) Results
To what extent are you feeling...
NO stress
(Coping fine, no problems)
Some stress
Moderate stress
A lot of stress
Extreme stress
(Health at risk, feeling at "end of rope")
Your priorities
Are you having feelings of being overwhelmed, overworked, and/or overburdened?
Your priorities
Has there been a change in your relationship with your spouse/relative?
Your priorities
Have you noticed any changes in your social life?
Your priorities
Are you having any conflicts with your previous daily commitments? (e.g., work/volunteering)
Your priorities
Do you have feelings of being confined or trapped by the responsibilities or demands of caregiving?
Your priorities
Do you ever have feelings related to a lack of confidence in your ability to provide care?
Your priorities
Do you have concerns regarding the future care needs of your spouse/relative?
Your priorities
Are you having any conflicts within your family over care decisions?
Your priorities
Are you having any conflicts within your family over the amount of support you are receiving in providing care?
Your priorities
Are you having any financial difficulties associated with caregiving?
Your priorities
Downloaded from CaregiverSelfCarePlan.ca
Adapted from Kingston Scales Institute – Assessment of Caregiver Stress
© 2024 Teva Canada Limited
www.tevacanada.com/en/canada
Caregiver Self-Care Plan
Downloaded from CaregiverSelfCarePlan.ca
Date: October 23, 2024
Pain Point
Describe what you would like to change to improve this aspect of caregiving.
Describe immediate steps that you can take to help improve this aspect of caregiving.
Describe the type of support and resources you will need to make this change.
Downloaded from CaregiverSelfCarePlan.ca
Adapted from Kingston Scales Institute – Assessment of Caregiver Stress
© 2024 Teva Canada Limited
www.tevacanada.com/en/canada
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