West Kootenay Boundary Caregiver Support » Caregiver Intake Form Caregiver Information Form PLEASE USE THIS FORM IF YOU ARE A CAREGIVER Caregiver IntakeDate: (mm/dd/yy): *How did you find out about West Kootenay Boundary Caregivers Support? *First Name *Last Name *Date of Birth (mm/dd/yy) *Main Phone *Type of connection *Cell PhoneLand LineText Messsages? *YesNoVoicemail? *YesNoEmail *Street Address *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *How do you identify? *FemaleMaleNon-binaryTransgenderOtherPrefer not to sayMarital status: *MarriedCommon lawSingleDivorcedWidowedPrefer not to discloseLiving Arrangements *Living aloneDo not live aloneUnknownPrefer not to discloseOtherLanguage(s) spoken *EnglishFrenchIndigenous language(s)RussianGermanSpanishTagalogMandarinCantoneseHindiFarsi/PersianJapaneseKoreanPortuguesePunjabiUkranianOtherEthnic Origin *Black (African, Caribbean descent)ArabChineseFilipinoIndigenous (First Nations, Metis, Inuit)JapaneseKoreanEast Asian (e.g. Chinese, Japanese, Korean)South Asian (East Indian, Pakistani, Sri Lankan)Southeast Asian (Vietnamese, Cambodian, Laotian, Thai)West Asian (Iranian, Afghan)Indigenous (First Nations, Metis, Inuit)Latin, Central, or South AmericanWhite (European descent)Do not knowPrefer not to discloseOtherDo you identify as a member of an underserved or equity deserving group? Examples might include: experiencing cultural and/or linguistic barriers; deaf and hard of hearing; experiencing elder abuse; experiencing mobility barriers; 2SLGBTQIA+; newcomers/ temporary residents; people with disabilities; permanent residents (immigrants and refugees); at risk of homelessness; at risk/experiencing mental health issues; at risk/experiencing physical health issues; other.YesNoSingle Person Income - Living alone *At or below $32290$32291 - $571999 Over $57200N/A (More than one person in household)Prefer not to discloseHousehold Income - 2 or more people in the home *At or below $49310$49311 - $107699Over $107700N/A (One person in the home)Prefer not to discloseHow often do you feel that you lack companionship? *Hardly everSome of the timeOftenPrefer not to discloseHow often do you feel left out? *Hardly everSome of the timeOftenPrefer not to discloseHow often do you feel isolated from others? *Hardly everSome of the timeOftenPrefer not to discloseRelationship to care recipient: *Spouse/PartnerParent/GuardianAdult Child/Adult Child-in-LawSiblingFriend or NeighbourGrandchildNiece or NephewOtherDo you consider yourself to be: (Check all that apply) *Primary CaregiverSecondary CaregiverTeam CaregiverDistance CaregiverHow many days a week are spent caregiving?123456Please select all that apply to you, the caregiver *At risk of homelessnessAt risk of or experiencing mental health issuesAt risk of or experiencing physical health issuesCultural and/or linguistic barriersDeaf and hard of hearingExperiencing elder abuseExperiencing mobility barriersLGBTQ2+Low to moderate fragilityNewcomer/Temporary residentPeople with disabilitiesPermanent residentSocially isolated/lonelyOtherRelationship to care recipient: *Adult Child/Adult Child-in-LawFriend/NeighbourGrandchildNiece/NephewParent/GuardianSiblingSpouse/PartnerOtherDo you consider yourself to be: (Check all that apply) *Primary CaregiverSecondary CaregiverTeam CaregiverDistance CaregiverHow long have you been in the caregiver role(s)? *Less than 1 year1-2 years3-5 years6-10 yearsOver 10 yearsHow many people are you caregiving for?How many HOURS per day are spent caregiving? *Less than 11-23-56-10Over 10How many DAYS per week are spent on caregiving? *1234567What activities of daily living do you provide (ADL)? *Mobility in bedTransferMobility in homeMobility outside of homeDressingEatingToilet useBladder/bowel carePersonal hygieneBathingOtherWhat instrumental activities of daily living do you provide (IADL) *Substance use managementTransportationMeal preparationHouseworkManaging financesManaging medicationShoppingOtherCare Recipient Information (if caring for more than 1 person, please respond based on the care recipient you are most involved with)First Name *Last Name *Name of Care Recipient *Does care recipient live with you? *YesNoCare recipient accommodation type? *HouseSuiteTownhouseApartment/CondoAssisted LivingMobile HomeSubsidizedOtherCare recipient living arrangement? *Living AloneWith SpouseWith FamilyRoommate(s)OtherWhat is/are the health concern(s) driving the majority of your caregiving efforts? *CancerDiabetesMental Illness (Addiction, Depression, Anxiety, etc.)DementiaNeurologicalCardiovascularAging/FrailtyVision ImpairmentsInjuryArthritisDevelopmental DelayOtherComments:Once you submit the form a representative of the West Kootenay Boundary Caregivers Support will be in contact with you.Send Message
