Caregiver Intake Profile - Seniors & Caregivers

SECTION 1: GENERAL INFORMATION

Name

First Last

Preferred Name

Date of Birth

Age

Gender

Pronouns

E.g., she/her, he/him, they/them, etc.

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

Phone (Home)

Phone (Mobile)

Emergency Contact Name

Emergency Contact Phone Number

SECTION 2: PERSONAL PROFILE

How did you hear about the Caregiver Coach and Peer Facilitator Program?

Caregiving Situation: Please describe your caregiving responsibilities.

Reason for Referral: What do you hope to gain/learn through working with a Caregiver Coach?

Circle of Support: From whom/where do you currently receive support?

SECTION 3: MEETING AND COMMUNICATION PREFERENCES

How often would you like to meet with a coach?

What is your preferred form of contact?

(phone, email, in person)

How long are you interested in participating in the program for?

SECTION 4

Are there specific aspects of caregiving that you would like assistance with?

Ex: Navigating resources, self-care, etc.

What other resources or forms of support can we provide you with/would you like to see in the future that would help you thrive as a caregiver?

Do you have any questions or concerns about being matched with a Caregiver Coach? Are there any barriers that may inhibit you from fully participating?

SECTION 5: CONSENT TO PARTICIPATE

By providing responses to the following and submitting this form, you acknowledge that you understand the parameters of the Caregiver Coach Program and agree to participate with respect to our guidelines and policies.

NAME: Please enter your full name

SIGNATURE: Please enter your full name to act as your signature here.

WITNESS: Please enter the full name of your witness here.

DATE: Please enter the current date here.

Phone

This field is for validation purposes and should be left unchanged.