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.