Care Receiver Application

Name:

Street

Street 2

City

State

Zip

Phone (home)

Email

Gender

MaleFemale

Date of Birth

Legal Status: Responsible for SelfUnder Guardianship/ConservatorshipUnder CommitmentPower of Attorney

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

Name:
Relation to Care Receiver:
Address or Email:

Caregiver Support Services

Caregiver CoachingHome Health CareHomemakingRespite Care

Local Transportation Medical AppointmentsShopping Assistance

NOT available if on MA

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? Once Every Two WeeksOnce a WeekOnce a Month

Who would you prefer to assist you? Doesn't MatterFemaleMaleFrom My ChurchFrom My Community

Health Status

Are you on Medical Assistance (NOT Medicare)? NoYes

Are you on Medicare? NoYes

Have you ever served in the military? NoYes

If yes were you a service connected Disabled Veteran? NoYes

Mobility Gets Out IndependentlyNeeds AssistanceHomebound

Personal Care IndependentNeeds AssistanceTotal Assistance

Emotional Status GoodModerateOther

Vision GoodImpairedModerate

Hearing GoodImpairedModerate

Speech GoodImpairedModerate

Social FewSomeMany

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

Special Dietary needs

Allergies

Living Situation AloneWith FamilyWith SpouseWith FriendOther

Do you smoke? YesNo

Do you have memory concerns? YesNo

How many people live with you?

Do you have pets in your home? YesNo

What type of pets?

Emergency Contact

Name

Phone

Primary Physician Name

Physician Phone

Please check other services you are currently using Adult Day ServicesSanford Homecare & HospiceMeals on WheelsCountry Health & Human ServicesSenior CenterTransportation Services

Income

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” or if left blank no sliding fee will be used and you will be billed as private pay. Based on the sliding fee and the number of hours per week requested, we may ask for a one month deposit before starting services.

Please check ONLY ONE LINE that best reflects your household’s gross MONTHLY income. Please include yourself in the Family Size.

Respite Care Only if interested

Primary Caregiver Name

Primary Caregiver Age

Primary Caregiver Date of Birth

Address:

City:

Zip:

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

Referral Source

Source ChurchFamilyFriendsNewspaperPresentationRadio/TVMedicalSchoolSelfOther

Referring Partner

Optional Information

Race African AmericanHispanicNative AmericanWhiteOther

If Native America, Tribe Affiliation

Ethnicity HispanicNon-Hispanic

Religion Baha'iBaptistCatholicEpiscopalEvangelicalJevhovah WitnessLutheranMethodistOtherPresbyterianSeventh Day AdventistUnitarian

Name of congregation:

Any additional comments?