West Kootenay Boundary Caregiver Support » Caregiver Information Form Caregiver Information Form PLEASE USE THIS FORM IF YOU ARE A CAREGIVER Caregiver InformationDate: (mm/dd/yy): *How did you find out about West Kootenay Boundary Caregivers Support?First Name *Last Name *Home Phone *Cell PhoneText Messsages?YesNoVoicemail?YesNoEmail *Date of Birth (mm/dd/yy) *How do you identify? *MaleFemaleOtherPrefer not to sayStreet Address *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *Relationship to care recipient: *Parent/GuardianSpouse/PartnerAdult Child/Adult Child-in-LawSiblingFriend/NeighbourOtherDo 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? *Care 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 *Age of care recipient? *Care recipient location (city/province)? *Does care recipient live with you? *YesNoIf yes, for how long:Care recipient accommodation type? *HouseSuite in HouseTownhouseApartment/CondoAssisted LivingMobile HomeSubsidizedOtherCare recipient living arrangement? *Living AloneWith SpouseWith FamilyRoommate(s)OtherFamily or roommates living in the home? *YesNoIf yes, comment:Marital status:MarriedCommon lawSingleDivorcedWidowedOnce you submit the form a representative of the West Kootenay Boundary Caregivers Support will be in contact with you.Send Message
