Caregiver Wellness Initiative Application
Please complete the following application to determine eligibility for mental health counseling services. This application is for caregivers who have not previously received Caregiver Wellness Initiative assistance. 

The completion of this application does not guarantee the awarding of financial assistance from Alabama Lifespan Respite. Please note that while Alabama Lifespan Respite wishes we could help all qualified individuals who seek assistance, regrettably we only have limited funds to meet the needs of qualified caregivers. Therefore, we can only respond to requests based on our available resources.

*IF YOU ARE CURRENTLY EXPERIENCING A MENTAL HEALTH CRISIS, PLEASE STOP NOW AND CALL THE NATIONAL CRISIS HOTLINE AT 988 TO SPEAK WITH A MENTAL HEALTH PROFESSIONAL.
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Have you applied for and received mental health counseling assistance from Alabama Lifespan Respite in the last 12 months?

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Are you currently receiving respite reimbursement through Alabama Lifespan Respite? *

Do you believe you are at risk for hurting yourself or others?

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Are you unable to care for yourself or your loved one(s) or to function effectively in your daily routines due to a mental health crisis? 

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On a scale of 1-10, please indicate your current stress level as related to being a full-time caregiver. *
On a scale of 1-10, please indicate the impact being a full-time caregiver has on your relationships with others (i.e. your spouse, other family members, and/or friendships). *
On a scale of 1-10, please indicate how isolated you may feel from family, friends, and/or community as a full-time caregiver. *
Are you experiencing any of the following? (Please check all that apply) *
Required
Briefly describe how/why you may benefit from mental health counseling services as a caregiver: *
If approved to receive mental health counseling services, would you be willing to complete one pre-counseling survey and one post-counseling survey online (approximately 10 minutes each) to help ALR determine the effectiveness of this program? *
How would you prefer to receive mental health counseling services? *
Do you have internet service at your residence, or access to internet service? *
Do you need a wifi-enabled tablet in order to receive mental health counseling services through Telehealth? *
If you would prefer to receive mental health counseling services in-person at a provider's office, how far are you willing to travel to receive in-person services?
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Your First & Last Name *
Email address *
Phone number *
Select the Alabama county in which you reside: *
After submitting this form, an ALR staff member will be in touch within 5 business days to notify you of the status of your application. Thank you!
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