Caregiver Program Application   Logo
  • 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
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  • *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. **

  • Care Recipient Information

    A care recipient is the person for whom you are providing care.
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  • 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.

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

    Income/Asset Statement (This information applies to both programs)
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    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'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.

  • 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.

     

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  • 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)
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