To receive services, an application must be on file. Applications must be mailed to:

Northwoods Caregivers
616 America Ave
Suite 170
Bemidji MN 5660

If you are unable to print, please Contact Us and we’ll gladly work with you.

Online Application

Name:

Street

Street 2

City

State

Zip

Phone (home)

Email

Gender

Date of Birth

Legal Status:

*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

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

Health Status

Are you on Medical Asisstance (NOT Medicare)?

Mobility

Personal Care

Emotional Status

Vision

Hearing

Speech

Social

Living Situation

Referral Source

Source

Referring Partner

Please check other services you are currently using

Optional Information

Race

Religion

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.

Family Size: 1

Family Size: 2

Family Size: 3

Family Size: 4

Family Size: 5

Family Size: 6

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?