Family Caregiver Support Program: Intake Form

The Family Caregiver Support Program offers caregivers a chance to receive much-needed respite. It is a program funded under the Older Americans Act, through Federal and State funding and in partnership with the Alzheimer’s Association. To be eligible, the care receiver must have substantial deficits in their activities of daily living or have a medical diagnosis of Alzheimer’s, dementia, or related disorder. Please see the Alzheimer’s/ Dementia Diagnosis Form if applicable.

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FISCAL YEAR _______________ # _________________

ATTENTION:

This form MUST be completed by the caregiver listed on the intake form. It is NOT appropriate for a medical professional, social worker, case manager, or any other person to fill out this form on behalf of a client/caregiver.
Caregiver Name(Required)
Care Receiver Name(Required)
MM slash DD slash YYYY

CAREGIVER INFORMATION

Are you a paid caregiver?(Required)
Client Status:(Required)
Do you have Internet Access?(Required)
Caregiver Address(Required)
Caregiver County(Required)
MM slash DD slash YYYY

CAREGIVER DEMOGRAPHICS

Caregiver Gender(Required)
Caregiver Ethnicity(Required)
Caregiver Race(Required)

Caregiver Monthly Household Income(Required)
Caregiver Marital Status(Required)
Caregiver's Relationship to Care Recipient(Required)

CARE RECIPIENT INFORMATION

To be eligible, the care receiver must have substantial deficits in their activities of daily living or have a medical diagnosis of Alzheimer’s, dementia, or related disorder.
Care Recipient Address(Required)
Care Recipient County(Required)
Do you have Internet Access?(Required)
MM slash DD slash YYYY

CARE RECIPIENT DEMOGRAPHICS

Care Recipient Gender(Required)
Care Recipient Ethnicity(Required)
Care Recipient Race(Required)

Care Recipient Marital Status(Required)
Care Recipient Military Service(Required)

CARE RECIPIENT CONDITION

Does the care receiver have a condition that causes limitations in activities?(Required)
Due to cognitive or other mental impairment, does the care receiver require substantial supervision to maintain their health and safety?(Required)
Care Receiver Condition(s):(Required)
Select all that apply.
Has the care receiver been diagnosed, by a Physician, to have Alzheimer's or a related dementia?(Required)
*If you selected "Yes", please download the Alzheimer’s Disease and Related Disorders Physician Diagnosis Statement Form by clicking the link below. This form must be completed and signed by the care receiver's physician.
*CLICK HERE TO DOWNLOAD FORM: Alzheimer’s Disease and Related Disorders Physician Diagnosis Statement Form
Is the care recipient currently receiving services from:(Required)
Select all that apply.
Services Requested:(Required)
Select all that apply.

FAMILY CAREGIVER SUPPORT PROGRAM: INTAKE FORM - RELEASE OF INFORMATION

Caregiver Name:(Required)
Care Recipient Name:(Required)
Caregiver Consent(Required)
SIGNATURE IS REQUIRED TO RECEIVE SERVICES
Clear Signature
MM slash DD slash YYYY

If you would like to receive a copy of your completed application, please provide the email address to which you would like the application sent.
This field is for validation purposes and should be left unchanged.