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): *First Name *Last Name *How did you find out about West Kootenay Boundary Caregivers Support? *AdvertisementBC 211Case workerCommunity-based agencyFriend/FamilyHost-organization (Local Hospices)NurseOther allied health professionalPhysicianSelf-referralSocial workerUnknownOtherDate of Birth (mm/dd/yy) *Personal Health NumberHome Phone *Cell PhoneText Messsages? *YesNoVoicemail? *YesNoEmail *Street Address *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *How do you identify? *FemaleMaleNon-binaryOtherPrefer not to sayMarital status: *Common lawDivorcedMarriedSingleWidowedPrefer not to discloseLiving Arrangements *Do not live aloneLiving alonePrefer not to discloseHousehold Income *Less than $35000$35000 or morePrefer not to discloseEthnic Origin *ArabBlack (African, Caribbean descent)ChineseFilipinoIndigenous (First Nations, Metis, Inuit)JapaneseKoreanLatin AmericanSouth Asian (East Indian, Pakistani, Sri Lankan)Southeast Asian (Vietnamese, Cambodian, Laotian, Thai)West Asian (Iranian, Afghan)White (European descent)OtherPrimary Language *Please 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 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)? *BathingBladder/bowel careDressingEatingPersonal hygieneMobility in bedMobility in homeMobility outside of homeToilet useTransferOtherWhat instrumental activities of daily living do you provide (IADL) *HouseworkManaging financesManaging medicationMeal preparationShoppingSubstance use managementTransportationOtherHow many people are you caregiving for? *What types of INDIVIDUAL support(s) are you seeking?Caregiver navigationCircle of supportInformal respiteInformation and referralOne-to-one supportOtherWhat types of GROUP support(s) are you seeking?Caregiver peer support groupsEducation and workshopsGroup activitiesSpecial eventsOtherCare 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 *Date of BirthMonthDayYearCare recipient location (city/province)? *Care recipient living arrangement? *Living AloneWith SpouseWith youWith FamilyRoommate(s)OtherCare recipient accommodation type? *HouseSuite in HouseApartment/CondoAssisted LivingLong Term CareMobile HomeSubsidizedTownhouseOtherPrimary Health Concerns *Aging/FrailtyArthritisCancerCardiovascular (Heart disease, Stroke...)DementiaDevelopmental delayDiabetesInjuryMental illnessNeurological disorder (Alzheimer, Brain injury, Parkinson, MS, Epilepsy...)Vision impairmentOtherOnce you submit the form a representative of the West Kootenay Boundary Caregivers Support will be in contact with you.Send Message
