To receive services, an application must be filled out.
To submit an online application, please fill out the information below and hit “Submit.”
If you would like to print off an application and mail it in, please click on the form at the bottom of the page and mail the completed application to:
Date of Birth (mm/dd/yyyy)
Responsible for SelfUnder CommitmentUnder Guardianship/ConvservatorshipPower of Attorney
*If someone OTHER than the Carereceiver should receive Monthly Transportation Invoices and other mailings from Northwoods Caregivers, please list here.
Relation to Carereceiver
Address or Email
Caregiver Support Services
Caregiver CoachingHome ModificationHomemakingRespite CareAging Life Care ManagementHome Health Care
Local Transportation Medical Appointments (Not available if on MA)Shopping Assistance
Additional Interests to help us make a match (hobbies/interests, etc)
Other medical information (uses walker, oxygen, insulin dependent, diagnosis, etc)
How long do you need assistance (in hours)?
How often do you need assistance? Once Every Two WeeksOnce a WeekOnce a Month
Who would you prefer to assist you? Doesn't MatterFemaleMaleFrom My ChurchFrom My Community
Primary Physician Name
Please check other services you are currently using
Transportation servicesMeals on WheelsSenior CenterSanford HomeCare & HospiceCounty Health & Human ServicesAdult Day Service
Northwoods Caregivers has a “Fee for Service” for all Respite and Transportation Services (such as transportation to medical appointments, grocery shopping assistance and meal deliveries). Fees are determined by a Sliding Fee Scale as well as the number of miles driven each month. Please fill out the following information to determine your “fee”.
Please check ONLY ONE LINE that best reflects your household’s gross MONTHLY income. Please include yourself in the Family Size:
Are you on Medical Asisstance (NOT Medicare)? NoYes
Are you on Medicare? NoYes
Have you ever served in the military? NoYes
If yes are you a service connected disabled veteran? NoYes
Mobility Gets Out IndependentlyNeeds AssistanceHomebound
Personal Care IndependentNeeds AssistanceTotal Assistance
Emotional Status GoodModerateOther
Current Medical History (walker, oxygen, insulin dependent, medical diagnosis, Alzheimer’s, etc)
Special Dietary needs
Living Situation AloneWith FamilyWith SpouseWith FriendOther
Please check other services you are currently using Adult Day ServicesBeltrami Nursing ServicesMeals on WheelsNorth Country Home Care & HospiceSenior CenterTransportation Services
Race African AmericanHispanicNative AmericanWhiteOther
Religion Baha'iBaptistCatholicEpiscopalEvangelical Jevhovah WitnessLutheranMethodistOtherPresbyterianSeventh Day Adventist
Estimated Monthly Income
Primary Caregiver Name
Primary Caregiver Age
Primary Caregiver Date of Birth
How long has the primary caregiver been caregiving?
Primary Caregiver Gender FemaleMale
Is the Primary Caregiver raising grandchildren? NoYes
Is the Primary Caregiver living with the carereceiver? NoYes
Any additional comments?