Caregiver Form

Name:

Address:

City:

State:

ZIP:

Phone (land line):

Phone (mobile):

Email:

Date of Birth (MM/DD/YYYY):

I'm a Caregiver For My: SpouseFatherMotherBrotherSisterGrandparentSonDaughterFriendNeighbor

Have you been in contact with the Aging & Disability Resource Center of La Crosse County (ADRC)? YesNo

Would you like to receive more information from the Aging & Disability Resource Center? YesNo

Other Agencies providing assistance:

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:

Do you use mobility/adaptive equipment?:CaneWalkerWheelchairHearing AidsOxygen

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):

Can you get into:
CarTruckSUVVan

Do you use:City BusCounty BusTransport Service

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.

Please provide any information about yourself that will help in finding a lasting mentor match.

Hobbies:

Favorite Books, Movies, TV Programs:

What do you enjoy talking about?:

Where do you (or would you) like to travel?:

Share any additional interests here:
 

How did you hear about this program?

Provide support and encouragement to caregiver(s) of a recipient

Please check all that are of interest (Time given denotes acceptable length of service)

Phone, Email, Visiting Call, email or visit at least once a week to encourage and support (2-4 hrs/month)

Socialization Spend time with caregiver and recipient for socialization in the community (2-4 hrs/month)

Attend Lunch Bunch or Support Groups Provide transportation for caregiver and recipient (2-4 hrs/month)

Office Volunteer Assist in the office with mailings or newsletter, compiling mentor hours, etc. (2 hrs/month)

Other? (Time varies)

Best time to Call:

Frequency:DailyWeeklyEvery Other WeekMonthlyAs Needed

Best Time:MorningAfternoonEveningDuring the WeekWeekends

Do you routinely leave the area for an extended time at a particular time each year?
 NoYes

If so, when?