Faith in Action: Elder Outreach

Care Receiver Application for Assistance

Please note that all information contained in this application is considered confidential

Date:  ________ Intake person________________   Reference #__________

Care receiver name: _______________________________________________

Age:______DOB___________Gender__________Ethnicity________________

Address:_________________________________________________________

Phone of care receiver_________________guardian_____________________

Cell phone______________________Pager____________________________

Other FIA care recipients in the home?:  (  ) yes  (  ) no

Name/ relationship: ________________________________

Person providing information for application if other than the care receiver

Name:________________________________________________________

Relationship or Agency:____________________________________________

Address:_________________________________________________________

________________________________________________________________

Phone number(s)__________________________________________________

What is the primary language of the care receiver_________________________

Is an English speaking volunteer adequate?  (  ) yes   (  ) no

Is the care receiver affiliated with a faith community? (  ) yes (  ) no

If yes please indicate the name and phone number of the faith community

_______________________________________________________________

Would you prefer a member of your religious group to assist you?  (  ) yes  (  ) no (  ) no preference

Emergency contact name_____________________Relationship____________

Address__________________________________________________________

Day phone number_________________Evening phone numbers____________

Cell phone_____________________Pager___________________________

Email Address:_________________________________________________

Emergency contact name_____________________Relationship____________

Address__________________________________________________________

Day phone number_________________Evening phone numbers____________

Cell phone_____________________Pager___________________________

Email Address:__________________________________________________

Medical problems of care receiver – please list below: ________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________

Does the care receiver need assistance with walking/ getting around ( ) yes ( ) no

If yes – please explain _____________________________________________

Does the care receiver use a cane___walker___wheelchair____Immobile_____

Does the care receiver have vision impairment____hearing impairment_______

Does the care receiver have significant memory impairment_______________

Neighbor contact: Please list the name address and phone number or two neighbors who can check on the care receiver in case of an emergency:

Name___________________________ Name___________________________

Address________________________Address___________________________

Phone(s)________________________Phone(s)__________________________________________________________________________________________

Does anyone have an extra key? (  ) yes  (  ) no

Name:_______________________________Phone_______________________

Closest Relative:

Name:________________________________Relationship_________________

Address:________________________________________________________

Email Address:___________________________________________________

Phone Number(s):_________________________________________________

Please indicate who lives in the residence with the care receiver, their relationship with the care receiver, and when they are present in the home____________________________________________________________________________________________________________________________

Please indicate who visits the residence of the care receiver frequently________

________________________________________________________________

Services Requested

Please circle the services or assistance that you need at this time. As other needs arise you may call the Faith in Action office or your faith community coordinator.

1.                  telephone reassurance                           7.         light housekeeping

2.                  friendly/compassionate visits                8.         pet care

3.                  respite relief for families (2 to 3 hrs.)    9.         plant care

4.                  light maintenance and repair                 10.       transportation (not offered)

5.                  groceries / shopping                               11.       other—please specify

6.                  meal delivery

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

Please indicate any other types of assistance currently being received by the care receiver (e.g., home health, social services, hospice, etc.) and give the name and phone number of the agencies.

________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________

Other information

Number and types of pets in the home (e.g. breed of dog)__________________

________________________________________________________________

Hobbies and Interests_______________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________

We do not discriminate on the basis of income.  We would like to know your approximate level of income so that we can report to our funding sources general information about the population we serve. 

What is your current yearly income level (OPTIONAL):

□ $20,000 or under               □ $40,000-$60,000

□ $20,000-$40,000              □ $60,000 or over

Consent Form

Faith in Action: Elder Outreach

Volunteer Service

Consent: I ______________________________________  give Faith in Action: Elder Outreach permission to provide volunteer(s) with need to know information to assist me with services and assistance requested,  and I give permission for Faith in Action: Elder Outreach to contact neighbors, family, health care providers or agencies if necessary for the well being or safety of the care recipient.  If health care providers or agencies are contacted I also give my consent for them to follow-up and contact me and my guardian.

_________________________    ___________________________       _______ 

Signature of Care Receiver             Signature of Guardian                      Date

___________________________                                                                  _______

Faith in Action Volunteer                                                                                          Date

 If you have any questions contact the Faith in Action: Elder Outreach office at 859-252-1365