To receive services, an application must be on file. Applications must be mailed to:
Northwoods Caregivers616 America AveSuite 170Bemidji MN 5660
If you are unable to print, please Contact Us and we’ll gladly work with you.
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.
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)
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
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
Current Medical History (walker, oxygen, insulin dependent, medical diagnosis, Alzheimer’s, etc.)
Special Dietary needs
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?
Primary Physician Name
Please check other services you are currently using Adult Day ServicesSanford Homecare & HospiceMeals on WheelsCountry Health & Human ServicesSenior CenterTransportation Services
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.
$0-$980$981-$1,471$1,472-$1,971$1,962-$2,453Greater than $2,453
$0-$1,327$1,328-$1,991$1,992-$2,655$2,656-$3,318Greater than $3,319
$0-$1,865$1,866-$2,796$2,798-$3,729$3,730-$4,660Greater than $4,661
$0-$2,245$2,246-$3,650$3,651-$4,414$4,415-$5,609Greater than $5,610
$0-$2,720$2,721-$4,076$4,077-$5,382$5,383-$6,795Greater than $6,796
$0-$3,306$3,307-$4,965$4,967-$6,554$6,554-$8,277Greater than $8,278
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
Race African AmericanHispanicNative AmericanWhiteOther
If Native America, Tribe Affiliation
Religion Baha'iBaptistCatholicEpiscopalEvangelicalJevhovah WitnessLutheranMethodistOtherPresbyterianSeventh Day AdventistUnitarian
Name of congregation:
Any additional comments?