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?

Yes

No

Is the caregiver paid to provide care to the care recipient?

Yes

No

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?

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

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 paid to provide care to the care recipient?

Please check all the items that apply to the caregiving recipient

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.

Has the caregiver received a publicly-funded respite break within the last three months?

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 anything else you'd like to to tell us about your respite needs?