Care Recipient Form

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Personal information
  • YesNo
  • CHF (Congestive Heart Failure)COPD (Chronic Obstructive Pulmonary Disease)Macular Degeneration Multiple Sclerosis Cerebral Palsy Parkinson's Disease EpilepsyLupusRheumatoid ArthritisKidney DiseaseCancer
  • CaneWalkerWheelchairHearing AidsOxygen
  • YesNo
  • CigarettesPipeOther
  • Must abstain while Mentor is present.
  • DogsCatsBirds
  • YesNo
  • 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.
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