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Click Here to View Printable Application Name: ______________________________________________
Date of Birth:______________________
Marital Status: Single__ Married___ Widowed__ Other___ Social Security Number_________________________ Address:____________________________________________ Phone: (Home)______________________
(Work)_______________________
(Cell)________________________ Emergency Contact:_____________________________________
Phone:______________________________________
Caregiver Information:
Name of Person:_______________________________________
Address, if not the same: _______________________________
_______________________________
Medical Conditions of caregiver: __________________________
_____________________________________________________
_____________________________________________________ Current perception of health status of caregiver: ____________________
_____________________________________________________________
of client: ______________________________________________________ _______________________________________________________________ Medical Doctor/PCP Name and Phone: ______________________
______________________________________________________ Specialists/Type:________________________________________
Fall Risk Assessment: ________________________________________________
____________________________________________________________________
Functional Abilities:_____________________________________________
____________________________________________________________ Performance of activities of daily living (bathing, dressing, cooking, telephone
use, financial management, grocery shopping, housework, laundry,
transportation), and if unable to do, who performs these tasks:
___________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Emotional Issues: Depression/medication:__________________________________________
____________________________________________________________________ Coping capacity: _____________________________________________________
_____________________________________________________________________
Anxiety/Medication:______________________________________________
_____________________________________________________________________
_____________________________________________________________________
Social Isolation:_________________________________________________ Caregiver Burnout:__________ ______________________________________
Issues:_________________________________________________________ Spiritual Needs, if any:_____________________________________________
______________________________________________________________
Environmental Issues: Home Safety:___________________________________________________
_____________________________________________________________________ Accessibility of Home Environment: __________________________________
_____________________________________________________________________
_____________________________________________________________________
Name of Carrier and I.D. and/or group number of all Health Insurance Cards
including Co-Insurance: __________________________________________
_____________________________________________________________
_____________________________________________________________
Insurance Company Telephone Numbers:_____________________________
_____________________________________________________________
Important Phone Numbers/Caregivers/providers: ___________________________
_____________________________________________________________________
_____________________________________________________________________
What kinds of support do you have? __________________________________
______________________________________________________________
______________________________________________________________ What do you hope to gain from this support group? ________________________
_______________________________________________________________
____________________________________________________________
What do you hope to share with group members? __________________________
________________________________________________________________
________________________________________________________________
This group will meet every other week. Please inform facilitator if you are unable
to attend as close to meeting as possible. Payment will be appreciated at each
meeting. Thank you so much for your attention and respect for all other caregivers
in the group. I hereby give Caryl Diengott, MSW, LICSW, C-ASWCM, CSW-G, C-SWHC to have the access
to and contact with any and all colleagues, medical personnel to help facilitate community
resources on your behalf, if needed.
Signed: ___________________________________
Date:______________________________________
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