Caregiver Respite Voucher Program Caregiver Eligibility Caregiver's Name* Caregiver's Address* Caregiver's Email Caregiver's Phone Number* Caregiver's County of Residence*FranklinGranvillePersonVanceWarrenAge of Caregiver* Relationship to Care Recipient* Care Recipient's Name* Care Recipient's County of Residence*FranklinGranvillePersonVanceWarrenAge of Care Recipient* Number of Caregivers Involved in Care* How many hours of care do caregivers provide in a week?* Describe you caregiving situation?*How did you hear about our services?*Select all that apply. WRAL Website (wral.com) Kerr-Tar Area Agency on Aging Website (kerrtarcog.org) Facebook Word of Mouth Billboard TV/Radio Other If you selected "Other" above, please let us know how you heard about us. Does care recipient have Medicaid?* Yes No Does care recipient have memory loss or confusion?* Yes No Are you currently receiving financial assistance from any other sources (i.e. VA)?* Yes No If you answered YES to the previous question, please list source(s) below.Which activities of daily living can care recipient perform?*Select all that apply. Bathing Toileting Dressing Transferring (moving from place to place) Ambulating (moving around without an assistive device) Eating None of the above Which instrumental activities of daily living can care recipient perform?*Select all that apply. Home Management Medication Management Transportation Money Management Shopping Meal Preparation None of the above Is there additional information you'd like us to know?
