Caregiver Program Application

Caregiver Program Application

Please complete every element of this application to be considered for Caregiver Program Support. These two programs are: National Family Caregiver Support Program (NFCSP) and Connecticut Statewide Respite Care Program (CSRCP). Once completed, a representative from the Area Agency on Aging will be in touch with you within 5 business days. Any questions, please call 1-800-994-9422.
Caregiver Information

This is information about YOU as the Caregiver
Caregiver's Name*

First NameLast Name
Please indicate today's date:*

MonthDayYear
Gender (of the caregiver)*
Marital Status (for the caregiver) *
Date of Birth*

MonthDayYear
Date
Address of Caregiver: *

Street Address or PO Box

Street Address Line 2

CityState / Province

Postal / Zip Code
Please indicate the BEST phone number to reach you:*
Please enter a valid phone number.Format: (000) 000-0000.
Please re-enter your phone number:*
Please enter a valid phone number.Format: (000) 000-0000.
Email address: *
example@example.com
Caregiver's Relationship to the Care Recipient:*

BrotherDaughterDaughter-In-LawDomestic PartnerFatherGranddaughter/GrandsonGrandfatherGrandmotherNon-relativeSisterSonSon in LawWife/HusbandMotherConservator of Person or Conservator of Estate**Health Care Representative**Power of Attorney**Other
*Must only be checked if the caregiver is age 55 or older and is the primary caregiver for a child under age 18 or an adult child between age 18 - 59 with a disability. Non-Relative and Other Relative may be checked for these caregivers as well as caregivers of older adult. **If you are authorized to act as legal representative for the care recipient, please provide documentation of such authority. **
Language Spoken at Home*

EnglishSpanishOther (please specify)
English Proficiency (how well is English spoken?)*

Very WellWellNot WellNot at All
Ethnicity?*

Not Hispanic/LatinoHispanic/LatinoUnknown
Race*

American Indian/Alaskan NativeAsian/Asian AmericanBlack/African AmericanMiddle Eastern/North AfricanNative Hawaiian/Pacific IslanderWhite- Not Hispanic/LatinoWhite-Hispanic/LatinoOther
How did you hear about the Program? (Check all that apply) :*

Area Agency on AgingTVRadioInternetAgency ReferralOther (please specify)
If an agency referred you to us, please indicate which one below:
As a Caregiver, what do you find most stressful with your role? *
As a Caregiver, what are some things you need assistance to better fulfill your role? (example "I need help with grocery shopping": *
Care Recipient Information

A care recipient is the person for whom you are providing care.
Care Recipient Name*

First NameLast Name
Marital Status (for the care recipient) *
Gender (for the care recipient)*
Is the care recipient a Veteran or Dependent of a Veteran?*

YesNo
Date of Birth*

MonthDayYear
Date
Town of residence of care recipient (this is used to ensure your application gets to the right place)*
Mailing Address of Care Recipient*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please indicate the best phone number for the care recipient:*
Please enter a valid phone number.Format: (000) 000-0000.
Please re-enter the best phone number for the care recipient:*
Please enter a valid phone number.Format: (000) 000-0000.
Language Spoken at Home*

EnglishSpanishOther (please specify)
English Proficiency (how well is English spoken?)*

Very WellWellNot WellNot at All
Ethnicity?*

Not Hispanic/LatinoHispanic/Latino
Race*

American Indian/Alaskan NativeAsian/Asian AmericanBlack/African AmericanMiddle Eastern/North AfricanNative Hawaiian/Pacific IslanderWhite- Not Hispanic/LatinoWhite-Hispanic/LatinoOther
Type of Housing (Please check the one that applies to the care recipient):*

Private HomePrivate ApartmentSenior HousingCongregate HousingPublic HousingResidential Care HomeNursing HomeAssisted LivingOther (Please Specify)
Living Arrangement (Care Recipient)*

AloneWith Spouse OnlyWith Spouse/Partner & ChildrenWith Unmarried PartnerWith Children, no spouse/partnerWith GrandchildrenWith Other RelativesWith Others
Has the Care Recipient been diagnosed with:*

Alzheimer's diseaseEarly On-Set DementiaVascular DementiaLewy Body DiseaseFrontotemporal DementiaMixed DementiaParkinson's Disease with DementiaNo Diagnosis of any of the aboveI don't know
For those whose care recipient has Alzheimer's or Related Dementia that irreversible/deteriorating in nature, a physician's statement MUST be completed. The agency that your case is assigned will assist you with that process.
If there is a diagnosis of any of the above, what stage?
Does this person have a disability?*

YesNoI don't know
Primary Care Physician and Phone Number: *
Medical Diagnosis of Care Recipient (please list all known):*
Any Pets?*

YesNo
If Yes for Pets, please indicate what kind?
Are there any smokers in the home (care recipient)?*

YesNoI don't know
Does the Care Recipient Receive Medicaid? (Title 19?)*

YesNoI don't know
Is the Care Recipent applying for Medicaid (Title 19)?*

YesNoI don't know
Is the Care Recipient on the CT Homecare Program for Elders (CHCPE) or the Personal Care Attendant Program? (PCA)*

YesNoI don't know
Is the Care Recipient on a wait list for any Medicaid services?*

YesNoI don't know
If Yes for any of the above, what Medicaid services? Please list all:
Does the care recipient require assistance with the following activities? (Please check all that apply):

EatingBathing/WashingDressingUsing the toiletWalkingContinence (bladder/bowel control)Getting out of bed/chair
Does the care recipient receive any additional home or community-based services (such as a visiting nurse or going to an Adult Day Center)?*

YesNoI don't know
If Yes, what types of services does the care recipient currently receive
Does the Care Recipient have challenges/need help with any of the following activities? (Please check all that apply)

Planning/Preparing MealsShoppingManaging MoneyUsing TelephoneHousekeepingDoing LaundryTaking MedicineUsing Transportation
Income and Asset Statement (this information applies to both programs)

Income/Asset Statement (This information applies to both programs)
Please list the care recipient’s total sources of income, including the spouse's or other income. The following are considered income: Social Security (minus Medicare Part B and Part D Premiums), Supplemental Security, Railroad Retirement Income, Pensions, Wages, Interest and Dividends, Net Rental Income, Veteran’s Benefits, and any other payments received on a one-time recurring basis.
Monthly Income

Fill in all that are applicable. Please indicate N/A if not applicable.
Care Recipient Monthly Income is ($):*
Care Recipient's Spouse's Monthly Income is: ($)*
Your Care Manager will calculate the above incomes to determine program eligibility. Note: Spousal income information is used to identify other sources of support such as state funded benefits, and is not a determining factor of eligibility.17a-860(c)(1)(A) Conn.Gen.Stat.
Care Recipient's Liquid Assets
Please indicate liquid assets of the care recipient and his or her spouse. Assets owned with others may also be listed. Liquid assets are defined as an asset that can be converted into cash within twenty (20) business days. List account balances for all liquid assets, including checking accounts, certificates of deposit, savings accounts, individual retirement accounts, stocks, bonds, and all life insurance policies. Include all accounts in the applicant’s name as well as those in both the applicant’s and their spouse’s name. The house that the person resides in does not count as an asset.
Total Amount of Liquid Assets: *
Are there any joint assets?*

YesNoI don't know (Your Care Manager will help you figure this out).
If so with whom? (example: care recipient owns a rental property with their sister).
If an individual is authorized to act as legal representative for the care recipient, provide documentation of such authority (e.g. Power of Attorney, Health Care Representative, OR appointment of Conservatorship through Probate Court.). Documentation can be submitted to your local Area Agency on Aging (who will be in contact with you once your application is submitted and recieved).
Certificate of Authorization
1) I certify that the information on this form is true, accurate, and complete to the best of my knowledge.
Signature of Care Recipient or Authorized Representative or Responsible Person applying for the Caregiver Support Program on behalf of the Care Recipient. **An authorized representative is an adult, over the age of eighteen, who has written authorization to act on the behalf of an assistance unit of which he or she is not currently a member, and who would otherwise not be eligible to act without such authorization.** Signing as a Responsible Person does not create financial responsibility.*

Clear
Please indicate today's date:*

MonthDayYear
PERMISSION FOR RELEASE OF MEDICAL INFORMATION

CARE RECIPENT OR AUTHORIZED Representative: Please complete this page. **Due to HIPPA, you may need to complete a separate authorization with the designated health care provider.**
I, (name of care recipient), agree to the release of medical information to the Area Agency on Aging for the purpose of determining my eligibility for the Caregiver Support Program.

I (is the care recipient)
Name of Patient
Address
Phone
Date of Birth (XX/XX/XXXX)
Signature of Care Recipient or Authorized Representative. **An authorized representative is an adult, over the age of eighteen who has written authorization to act on the behalf of an assistance unit of which he or she is not currently a member, and who would otherwise not be eligible to act without such authorization. ** *

Clear
Please print the name of the Care Recipient
Please indicate today's date:*

MonthDayYear
Date
To be completed by the physician. * If you'd like to print this form, please click the ... next to the magnifying glass (zoom feature). This is on the right-hand side of the page.*
To be completed by the caregiver. * If you'd like to print this form, please click the ... next to the magnifying glass (zoom feature). This is on the right-hand side of the page.*
Do you need the "Physician Statement and "Co-Pay Agreement" printed and sent to your designated mailing address? Please check "Yes" or "No" below:

YesNo
Should be Empty:

Caregiver Program Application

Caregiver Information

Care Recipient Information

Income and Asset Statement (this information applies to both programs)

Monthly Income

Care Recipient's Liquid Assets

Certificate of Authorization

PERMISSION FOR RELEASE OF MEDICAL INFORMATION

I, (name of care recipient), agree to the release of medical information to the Area Agency on Aging for the purpose of determining my eligibility for the Caregiver Support Program.