Caregiver Support Application

In addition to you, who is currently providing care/meeting the needs of your care recipient or performing daily/weekly chores for your household?

Are you/is your family/care recipient currently receiving any other support(s) or community resources? If yes, please specify.

On a scale of 1-10 (1 being least supported and 10 being most supported), how well supported do you currently feel to continue your role as a caregiver?

Please select the services you’d be interested in receiving:(required)

Ready-to-cook meals Laundry service Respite Care Care coordination (available to members only)

Please select the service model you’d like to receive: (required)

Pay-per-service Standard membership Custom membership I'm not sure, I'd like someone to contact me to discuss the options

Connected Caregivers works diligently to provide support services at a price that is affordable and accessible to all families. However, if cost is a barrier to receiving support for your family, please let us know. While not guaranteed, we occasionally have funding from generous sponsors to offset some of the cost of services.

We will accept applications by considering both date of application and level of need. Although it is optional, if there is any other supporting information or documentation (e.g., diagnoses, referral/letter of recommendation from a medical/therapy provider/clergy member, etc., IEP/care plan, etc.) you’d like to provide, we will carefully review and consider this information as we determine level of need. All information will be kept entirely confidential.

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While we would love to be able to offer support to all caregivers/families who apply, we do currently have a waitlist and are adding families to our support network as quickly as we can as funding and volunteer base allows.

I understand submission of this application does not guarantee that I will receive support services from Connected Caregivers.

I understand that Connected Caregivers currently has a waitlist and that I will be contacted via email if my application is able to be approved.

Caregiver Support Application

Thank you for your response. ✨

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