Carereceiver Application
616 America Ave Suite 170 Bemidji, MN 56601
Email:
Fax: (218) 333-8263
Cindi Lee Jernigan, Executive DirectorMissy Thomas, Director of Care Services
(218) 333-8264 or toll free (888) 534-4432 (218) 333-8266
Carol Priest, Caregiver AdvocateSabrina Anderson, TransportationCoordinator(218) 333-8265 (218) 333-8262
Serenity Walker, Volunteer CoordinatorKaren Bedeau, Dementia Outreach Advocate
(218) 333-8262(218) 333-8262
In order for us to begin serving you, please complete
ALL 4 PAGES and SIGN the application on the bottom of the last page:
Name:______Date: ______
Address: ______City: ______Zip: ______
Home Phone: (______)______Cell Phone: (______)______
Email: ______Gender: ______
Date of Birth (MM/DD/YYYY): _____/______/______Age: ______
Legal Status: ____Responsible for Self ____Under Guardianship/Conservatorship ____Under Commitment ____Power of Attorney
*If someone OTHER than the Carereceiver should receive Monthly Transportation Invoices and other mailings from Northwoods Caregivers, please list here.
Name:______Relation to Carereceiver:______
Addressor Email:______
I am seeking services in the following areas (check all that apply):
Caregiver Support Services Local Transportation
____ Respite Care ____ Shopping Assistance
____ Caregiver Coaching ____ Medical Appointments
____ Homemaking (Not available if on MA)
____ Home Modification
____ Aging Life Care Management
Additional interests to help us make a match (hobbies/interests, enjoyable outings, etc.) ______
I need assistance: ______hours:_____ a week _____ every two weeks _____ a month
I would like someone:
_____ from my church (please list on page 4) _____ from my community
_____ male ______female _____doesn’t matter
Health Status:
Are you on Medical Assistance(MA) (NOT Medicare): _____ Yes ____ No
Are you on Medicare? _____ Yes _____ No
Have you ever served in the military? _____ Yes _____ No
If yes, are you a service connected disabled veteran? _____ Yes _____ No
Mobility Personal Care Emotional Status
____ gets out independently ____ independent ____ good
____ needs assistance ____ needs assistance ____ moderate
____ homebound ____ total assistance ____ other
VisionHearingSpeech Social
____ good____ good____ good ____ many
____ moderate ____ moderate ____ moderate ____ some
____ impaired ____ impaired ____ impaired ____ few
Current Medical History(walker, oxygen, insulin dependent, medical diagnosis, Alzheimer’s, etc):
______
______
Special Dietary needs: ______
______
Allergies: ______
Living Situation
____ alone ____ with spouse ____ with family ____with friend ______list other
Emergency Contacts:
Name: ______Relationship:______Phone: (______)______
Primary Physician Name: ______Phone: (______)______
Please check other services you are currently using:
_____ Transportation services ____ Meals on Wheels____ Senior Center
_____ Sanford HomeCare ____ County Health____ Adult Day
& Hospice & HumanServicesServices
Northwoods Caregivers has a “Fee for Service” for all Respite and Transportation Services (such as transportation to medical appointments, grocery shopping assistance and meal deliveries). Fees are determined by a Sliding Fee Scale as well as the number of miles driven each month. There is Please fill out the following information to determine your “fee”.
Please check ONLY ONE LINE that best reflects your household’s gross MONTHLY income. Please include yourself in the Family Size:
Family Size: 1Family Size: 2Family Size: 3
____ $0-$902____ $0-$1,214____ $0-$1,518
____ $903-$1,354____ $1,215-$1,821____ $1,519-$2,276
____ $1,355-$1,805____ $1,822-$2,428____ $2,277-$3,305
____$1,800-$2,256____ $2,429-$3,035____ $3,306-$3,794
____ Greater than $2,257____ Greater than $3,036____ Greater than $3,795
Family Size: 4Family Size: 5Family Size :6
____ $0-$1,898____ $0-$2,373 ____$0-$2,966
____ $1899-$2,845____ $2,374-$3,556 ____$2,967-$4,445
____ $2,846-$3,750____ $3,557-$4,688 ____$4,446-$5,860
____ $3,751-$4,743____ $4,689-$5,929 ____$5,861-$7,411
____ Greater than $4,744____ Greater than $5,930____ Greater than $7,412
**PLEASE COMPLETE THE FOLLOWING QUESTIONS ONLYIF YOU ARE INTERESTED IN RESPITE CARE OR CAREGIVER COACHING:
Primary Caregiver Name: ______Relationship:______
Address: ______City: ______Zip: ______
Primary Caregiver email:______
Primary Caregiver phone:(______)______cell:(_____)______
Primary Caregiver DOB: ____/_____/______Primary Caregiver Age: ______
How long has the primary caregiver been caregiving? ______
Gender of Primary Caregiver: ______Male ______Female
Is the Primary Caregiver raising grandchildren? ______
Is the Primary Caregiver living with the Carereceiver? ______
Please remember a Caregiver Support Group is available through our agency in Bemidji, Bagley and Blackduck. For more information call Carol (218) 333-8265.
Referral Source:
____ friends ____ radio/TV____ presentation____medical ____ self
____ church ____ school____ newspaper____ family ______list other
Name of Referring Partner: ______
*Optional Information: (answers shared when answering Race and Religionwill be helpful when matching volunteer with carereceiver, and will also benefit as statistical information)
Race:
____ White____ Hispanic ____ African American ____ Native American ______List Other
If Native American, what is your Tribal Affiliation: ______
Ethnicity:______Hispanic______Non-Hispanic
Religion: Name of Congregation: ______
____ Catholic ____ Presbyterian ____ Baptist
____ Seventh Day Adventist____ Jehovah Witness ____ Baha’i
____ Evangelical____ Methodist ____ Unitarian
____ Episcopal ____ Lutheran ____ Other Name of other:______
Any additional comments/questions?
*Once we receive and process this application, please look for a Welcome Packet in the mail or by email, which ever you choose. In this packet will be your Carereceiver Manual and sliding fee determination, if applicable, among a few other important pieces of paperwork. This packet will give you all the information you need in order to proceed in receiving services.
Thank you for choosing Northwoods Caregivers
and we look forward to serving you!
Signature of client/guardian:______
(Required in order to provide services)
Date:______
Revised 4/20161