Caregiver Information Form

Caregiver Intake

Date: (mm/dd/yy): *

First Name *

Last Name *

Date of Birth (mm/dd/yy) *

Main Phone *

Type of connection *Cell PhoneLand Line

Text Messsages? *YesNo

Voicemail? *YesNo

Email *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Do you identify as a member of an underserved or equity deserving group?YesNoExamples 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.

How often do you feel that you lack companionship? *Hardly everSome of the timeOftenPrefer not to disclose

How often do you feel left out? *Hardly everSome of the timeOftenPrefer not to disclose

How often do you feel isolated from others? *Hardly everSome of the timeOftenPrefer not to disclose

Do you consider yourself to be: (Check all that apply) *Primary CaregiverSecondary CaregiverTeam CaregiverDistance Caregiver

How 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)

Name of care recipient? *

Care recipient date of birth? *

Care recipient locaton? *

Does care recipient live with you? *YesNo

Comments:

Once you submit the form a representative of the West Kootenay Boundary Caregivers Support will be in contact with you.

PLEASE USE THIS FORM IF YOU ARE A CAREGIVER

Caregiver Intake

Care Recipient Information (if caring for more than 1 person, please respond based on the care recipient you are most involved with)

Contact Information

Address

Toll Free

Email

West Kootenay Boundary Caregiver Support

Land Acknowledgement

Page Links

Support Groups

Resources

Calendar