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Peer Facilitator Intake
My first name is
*
My last name is
*
My email address is
*
Is the caregiver who would receive respite 18 years of age and a North Carolina resident?
*
Is the caregiver who would receive respite 18 years of age and a North Carolina resident?
Yes
No
Is the caregiver paid to provide care to the care recipient?
*
Is the caregiver paid to provide care to the care recipient?
Yes
No
Please check all the items that apply to the caregiving recipient
*
Please check all the items that apply to the caregiving recipient
Adult with Alzheimer’s disease or related dementia
Adult with other memory impairment
Child with developmental and/or physical disabilities
Adult with developmental and/or physical disabilities
Child with behavioral or emotional concerns
Child that needs assistance with multiple activities of daily living and/or chronic diseases
Minor grandchild living with and being raised by a grandparent as the primary caregiver
Adult that needs assistance with multiple activities of daily living and/or chronic diseases
Child or adult whose caregiver is in urgent need of respite as referred by the Division of Social Services, Adult Protective Services, or Child Protective Services
Other
Do the caregiver or the care recipient ongoing,
publicly funded
in-home services or other respite care, including adult day care services? If you are on a waiting list for publicly funded services but to not yet receive them, please check the No option.
*
Do the caregiver or the care recipient ongoing, publicly funded in-home services or other respite care, including adult day care services? If you are on a waiting list for publicly funded services but to not yet receive them, please check the No option.
Yes
No
Has the caregiver received a publicly-funded respite break within the last three months?
*
Has the caregiver received a publicly-funded respite break within the last three months?
Yes
No
Is there an emergency need for care. Emergency needs include a sudden, serious illness for the caregiver or someone in the caregiver's family other than the care recipient as well as other extenuating circumstances that make the caregiving responsibilities difficult or impossible.
*
Is there an emergency need for care. Emergency needs include a sudden, serious illness for the caregiver or someone in the caregiver's family other than the care recipient as well as other extenuating circumstances that make the caregiving responsibilities difficult or impossible.
Yes
No
Is there anything else you'd like to to tell us about your respite needs?
Submit