Family Caregiver Support Program - PDF - PDF

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					                              Family Caregiver Support Program
                                        ASSESSMENT

                                        Return assessment to:
                                   Larimer County Office on Aging
                                   2601 Midpoint Drive, Suite 112
                                       Fort Collins, CO 80525
                          Or FAX: Attn: Lynette McGowan at (970) 498-7625
Date: _____/_____/_____


                                     Caregiver Information
Name
                             First                                                      Last

Address                                                                                Apt #
City                                                  State                     Zip Code
Home Phone                                            Work Phone
Email                                                       SSN   (last 4 digits)

Date of Birth     _____/_____/_____         Age                             Sex       Male           Female
Race         African American                                     Marital Status                  Married
             American Indian/Native Alaskan                                                       Separated
             Asian/Pacific Islander                                                               Divorced
             Hispanic                                                                             Single
             White                                                                                Widowed
Relationship to Care Receiver       Husband               Daughter            Grandchild             Friend
                                    Wife                  Son                 Other Family           Partner

Veteran, is anyone in the immediate family a veteran?                        Yes           No
Assistance Provided by Caregiver
 Key Activities of Daily Living:
   Bathing                   Dressing                   Eating                  Transferring from bed/chair
   Toileting                 Walking                    Requires supervision due to dementia
Other, please describe:


 Instrumental Activities of Daily Living:
   Housework            Laundry                    Meal preparation/cooking                    Medication
   Shopping             Transportation             Money management                            Use of phone
Other, please describe:



                                                  Page 1 of 6                                       Revised 6/8/09
Is anyone else currently providing help with the activities of daily living of care receiver? If so, who?



Do you live with the person you care for?        Yes                 No
How long have you been caregiving?


How much time do you spend providing care each week (estimate)?



                             Care Receiver Information
Name
                             First                                                      Last

     Address and home phone are the same as the caregiver
Address                                                                                Apt #
City                                                 State                       Zip Code
Home Phone                                           SSN       (last 4-digits)
Date of Birth     _____/_____/_____               Age                    Sex         Male         Female
Primary Diagnosis
Race         African American                                         Marital Status           Married
             American Indian/Native Alaskan                                                    Separated
             Asian/Pacific Islander                                                            Divorced
             Hispanic                                                                          Single
             White                                                                             Widowed
Living Arrangements                                                    Estimated Monthly Income
          With spouse only                                                      Under $902
           Spouse & others                                                        $903 - $1,353
           Child(ren)                                                             $1,354 - $1,804
           Other relatives                                                        $1,805 - $2,706
           Other(s), not relatives                                                Over $2,706
           Alone
           Other, please specify

Home and Community Based Services (HCBS through Medicaid)
           Care receiver is currently receiving services through the HCBS Program
           Care receiver has applied for HCBS with Larimer County Options for Long Term Care




                                                 Page 2 of 6                                        Revised 6/8/09
                      Caregiving Support and Services
Caregiver Consultation / Assessment:
The purpose of a consultation is to provide guidance, support and assistance to caregiving families.
An individual consultation will be arranged with the caregiver and care receiver, with the caregiver
individually, or with other members of the family.

Respite Support:          Please check if you are applying for respite
A Respite Support Grant of $300 (per six months) can be provided for assistance with respite care
services to eligible caregivers. Please indicate your plan for respite services below:

In Home Respite                                                Out of Home Respite
    Private caregiver                                            Adult Day Care
    Companion Care Agency                                        Residential Respite
    Home Health Care Agency

Reason for Request:




Supportive Services:        Please check if you are applying for supportive services
Funds ($200 per year) may be available to help purchase items or supplies that can enhance the
caregivers ability to provide care and/or promote the dignity and independence of the care receiver
(this may include help with the purchase of special equipment, in-home assistive devices,
incontinence supplies, materials for small home modifications, and other caregiving supplies).
Please describe the item(s) that is needed to complement the care:




Other Services for Care Partners:
What other services or support do you or your loved one need? Please check items below:
   Adaptive/Assistive Equipment                              General Community Resource Information
   Advance Medical Directives                                Financial/Legal Issues
   Caregiver Support Groups                                  Individual Counseling/Emotional Support
   Dementia Resources                                        Minor Home Safety Modification

I would like more information on:
   Companion Care Agencies
   Home Health Care Agencies (i.e., therapy for fall prevention, home safety evaluation, assistive
   equipment needs, incontinence management)

Please describe any other assistance needed:




                                               Page 3 of 6                                 Revised 6/8/09
Caregiver Questions
What would make your caregiving role easier to manage?




What do you do to take care of yourself (hobbies, exercise, leisure activities, support groups)?




What is the most positive aspect of caregiving?




What is the most difficult aspect of caregiving?




How did you hear about this Family Caregiver Support Program?




Other Comments:




                                                   Page 4 of 6                            Revised 6/8/09
                                  Caregiver Consent
I, _____________________________, authorize the Larimer County Office on Aging to share the
information contained in my Family Caregiver Support Program Assessment in order to arrange and
coordinate services on my behalf. By signing below, I release the County Department from any
liability for supplying this information.


Signature                                                          Date




                      Disclaimer & Release of Liability
I understand that the Larimer County Office on Aging, its employees and any other Larimer County
employees or agents are not insurers or guarantors of the work or services performed nor are they
responsible for the suitability of the person doing the work requested by me in the Family Caregiver
Support Program Assessment, nor are they responsible for the personal safety of any person, and/or
any property related to the performance of services by persons outside of their control, including any
respite caregivers or caregiver consultants not employed by Larimer County. I release Larimer County
and the Larimer County Office on Aging agents, employees, and officers from any and all liability that
may arise as a result of the work performed in accordance with caregiver respite services or
consultant services that are paid for on my behalf.


Signature                                                          Date




                                Your Right to Appeal
If you think the Office on Aging has been unfair or has made a mistake concerning your eligibility for
services you have the right to a County Dispute Resolution Conference. This means you will be given
a chance to present your case for review by persons not responsible for the original decision to be
sure the decision was a proper one. Please contact the Office on Aging Program Manager at 2601
Midpoint Drive, Ste. 112, Fort Collins, CO 80525 or call (970) 498-7755 for information regarding this
process. If the decision from the Office on Aging Program Manager is not considered satisfactory,
then you may file an appeal with the Colorado Department of Human Services, State Unit on Aging at
1575 Sherman St., 10th Floor, Denver, CO 80203. Phone: 303-866-2800 or 1-888-866-4243.




                                              Page 5 of 6                               Revised 6/8/09
Family Caregiver Support Program


 Please return the Family Caregiver Support Program
         Assessment to the following address:




      Larimer County Office on Aging
     Family Caregiver Support Program
       2601 Midpoint Drive, Suite 112
          Fort Collins, CO 80525




Or FAX to Lynette McGowan at (970) 498-7625




 Please direct any questions regarding the assessment
   process to Lynette McGowan at (970) 498-7758




                       Page 6 of 6                      Revised 6/8/09