Caregiver Form

    Use the "tab" key to navigate between fields.
    Pressing "enter" or "return" submits the form.
    Personal information
    • I'm a Caregiver For My: SpouseFatherMotherBrotherSisterGrandparentSonDaughterFriendNeighbor
    • YesNo
    • YesNo
    Health
    • YesNo
    • CaneWalkerWheelchairHearing AidsOxygen
    • YesNo
    • CigarettesPipeOther
    • Must abstain while Mentor is present.
    • DogsCatsBirds

    • CarTruckSUVVan
    • City BusCounty BusTransport Service
    • 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.
    Volun-Peer Mentor Matching
    • Please provide any information about yourself that will help in finding a lasting mentor match.
    • Share any additional interests here:
      Mentors Will:
    • Have previous caregiving experience
    • Be a good listener with empathy and understanding
    • Be accepting and respectful of caregivers emotions and differences
    • Provide moral support
    • Share their caregiving experience, strength and hope
    • Make first contact and maintain contact with the caregiver at the time, frequency agreed upon
    • Understand the limitations and demands of the caregiver and respect their privacy and personal space
      Mentors Will Not provide the caregiver or recipient advice on:
    • Medical decisions
    • Family or Personal matters
    • Financial decisions
    • Administer medications
    • Provide personal care
    • Provide transportation
    Volun-Peer Mentor Services
    • 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)
    • (Time varies)
    • DailyWeeklyEvery Other WeekMonthlyAs Needed
    • MorningAfternoonEveningDuring the WeekWeekends
    • Do you routinely leave the area for an extended time at a particular time each year?
      NoYes
    • captcha

    Comments are closed.