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?