Caregiver Form

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    Personal information
    • I'm a Caregiver For My: SpouseFatherMotherBrotherSisterGrandparentSonDaughterFriendNeighbor

    • YesNo

    • YesNo

    • 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?

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