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:

Northwoods Caregivers
616 America Ave
Suite 170
Bemidji MN 56601
 
 
Questions? 218-333-8264 or toll free 888-543-4432
Email: info@northwoodscaregivers.org

Name:

Street

Street 2

City

State

Zip

Phone (home)

Email

Gender

Date of Birth (mm/dd/yyyy)

Legal Status

*If someone OTHER than the Carereceiver should receive Monthly Transportation Invoices and other mailings from Northwoods Caregivers, please list here.

Name

Relation to Carereceiver

Address or Email

Caregiver Support Services

Local Transportation

Additional Interests to help us make a match (hobbies/interests, etc)

Other medical information (uses walker, oxygen, insulin dependent, diagnosis, etc)

Assistance Needs

How long do you need assistance (in hours)?

How often do you need assistance?

Who would you prefer to assist you?

Emergency Contact

Name

Phone

Primary Physician Name

Physician Phone

Please check other services you are currently using

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:

Family Size 1
Family Size 2
Family Size 3
Family Size 4
Family Size 5
Family Size 6


Health Status

Are you on Medical Asisstance (NOT Medicare)?

Are you on Medicare?

Have you ever served in the military?

If yes are you a service connected disabled veteran?

Mobility

Personal Care

Emotional Status

Vision

Hearing

Speech

Social

Current Medical History (walker, oxygen, insulin dependent, medical diagnosis, Alzheimer’s, etc)

Special Dietary needs

Allergies

Living Situation

Referral Source

Source

Referring Partner

Please check other services you are currently using

Optional Information

Race

Religion

Income

Family Size

Estimated Monthly Income

Respite Care Only if interested

Primary Caregiver Name

Primary Caregiver Age

Primary Caregiver Date of Birth

How long has the primary caregiver been caregiving?

Primary Caregiver Gender

Is the Primary Caregiver raising grandchildren?

Is the Primary Caregiver living with the carereceiver?

Any additional comments?

PDF

Care Receiver Application Preview