Page 1 of 1
Care Partner Intake
My first name is
*
My last name is
*
My email address is
*
I am caring for ________
*
I am caring for ________
my sibling
my child
my significant other
my parent
my friend
Other
The person I am care about
*
The person I am care about
A
Has access to the Innovations Waiver
B
Is on the wait list to access the Innovations Waiver
C
Receives benefits some other way
D
Receives no support or benefits
E
I'm not sure
F
Other
The person I care about resides in:
*
The person I care about resides in:
A
The Raleigh-Durham area
B
Elsewhere in North Carolina
C
Other
The person or people I am caregiving for are:
*
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:
My stage of caregiving is best described as:
A
In the future, I may take on caregiving responsibilities
B
I am the sole or primary person caregiving
C
I am a secondary or backup person caregiving
D
I anticipate supporting the primary person caregiving
E
I have had caregiving responsibilities in the past
F
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:
Paid
Unpaid
84+ hours per week
40+ hours per week
20+ hours per week
0-20 hours per week
Please select any categories that you woulds like additional support for:
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:
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
Submit