Care Recipient Form

Name:

Address:

City:

State:

ZIP:

Phone (land line):

Phone (mobile):

Email:

Date of Birth (MM/DD/YYYY):

Do you have any medical conditions or concerns that the Volun-Peer Mentor should be aware of, or that you might need special consideration for? YesNo

If yes, please describe:

Medical condition(s):CHF (Congestive Heart Failure)COPD (Chronic Obstructive Pulmonary Disease)Macular Degeneration Multiple Sclerosis Cerebral Palsy Parkinson's Disease EpilepsyLupusRheumatoid ArthritisKidney DiseaseCancer

Other?

Description:

Do you use mobility/adaptive equipment?:CaneWalkerWheelchairHearing AidsOxygen

Other Agencies providing assistance:

Do you smoke? YesNo

If so, what do you smoke? CigarettesPipeOther

Must abstain while Mentor is present.

Do you have any pets? DogsCatsBirds

Pet's name(s):

Occupation (Former or Current):

Does anyone else live with you? YesNo

If yes, please list the name and date-of-birth of each other person:

Causeway Caregivers performs a background check under the direction of The Aging and Disability Resource Center of La Crosse County on all mentors, caregivers and care recipients to determine eligibility.