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Care Partner Intake

My first name is

My last name is

My email address is

I am caring for ________

my sibling

my child

my significant other

my parent

my friend

Other

The person I am care about

Has access to the Innovations Waiver

Is on the wait list to access the Innovations Waiver

Receives benefits some other way

Receives no support or benefits

I'm not sure

Other

The person I care about resides in:

The Raleigh-Durham area

Elsewhere in North Carolina

Other

The person or people I am caregiving for are:

Under 18 years old

18-35 years old

35-65 years old

Over 65

My stage of caregiving is best described as:

In the future, I may take on caregiving responsibilities

I am the sole or primary person caregiving

I am a secondary or backup person caregiving

I anticipate supporting the primary person caregiving

I have had caregiving responsibilities in the past

Other

Please share anything else you'd like us to know about your experience as a care partner navigating disability services and getting the support and resources you need on your journey.

My the workload of my caregiving role is:

Please select any categories that you woulds like additional support for:

Medicaid

Accessing respite care or home and community based services

Finding or applying for resources, such as the innovations waiver or tailored plans (Alliance, etc.)

Reducing social isolation, finding community or social events

Accessing medical or mental healthcare

Navigating school or IEP processes

Navigating the transition to adulthood

Understanding how I can make greater use of the Innovations Waiver or other supportive plans that I/the person I am caring for have

Finding supportive living environments

Other

Please indicate any barriers that you would like us to know about for yourself and/or the person you are caring for:

Difficulty accessing transportation

Financial barriers (i.e. most services are too expensive)

Lack of insurance or being under-insured

Anxiety or other mental health challenges with services or new situations

Major life or health changes recently

Other

	Paid	Unpaid
84+ hours per week
40+ hours per week
20+ hours per week
0-20 hours per week