weekly or daily check ins
👤 CAREGIVER INFORMATION
Name: ___________________________
Date: ___________________________
Week/Day: _______________________
❤️ HOW ARE YOU FEELING TODAY?
Mark all that apply:
☐ Tired
☐ Frustrated
☐ Anxious
☐ Numb
☐ Hopeful
☐ Motivated
☐ Sad
☐ Angry
☐ Overwhelmed
☐ Other: _______________________
🔋 ENERGY CHECK-IN
My energy level is:
☐ Full
☐ Half-Full
☐ Running Low
☐ Empty
My sleep last night was:
☐ Restful
☐ Interrupted
☐ Poor
☐ Barely Slept
🧠 MENTAL LOAD
Things that are weighing on my mind today:
One thing I can let go of today:
🌱 SELF-CARE REFLECTION
Did I do anything for myself in the last 24 hours?
☐ Yes
☐ No
If yes, what was it?
What small act of care can I give myself today?
☐ Take a 10-minute break
☐ Go for a short walk
☐ Talk to someone I trust
☐ Drink water mindfully
☐ Journal or pray/meditate
☐ Other: _______________________
📣 WHAT DO I NEED RIGHT NOW?
Physically:
☐ Food
☐ Rest
☐ Movement
☐ Water
☐ Other: ____________________
Emotionally:
☐ Validation
☐ Support
☐ Space
☐ Reassurance
☐ Other: ____________________
✍️ REFLECT & RELEASE
Today, I want to write or release:
🌞 AFFIRMATION OF THE DAY
(Choose or write one for yourself)
☐ “I am doing the best I can, and that is enough.”
☐ “It’s okay to ask for help.”
☐ “I deserve rest and compassion.”
☐ My own affirmation: _______________________________