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Care Recipient Application
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* Indicates required question
Client Name (first, middle, & last)
*
Your answer
Address (Street, City, State, Zip)
*
Your answer
Phone Number
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Gender
*
Male
Female
How did you hear about Faith In Action?
Your answer
Place of Worship
Your answer
Living Arrangements
*
Alone
Family
Spouse/Partner
Other:
Mobility Assistance
None
Cane
Walker
Wheelchair
Other:
Clear selection
Do you receive medical assistance?
Yes
No
Clear selection
Are you part of the Elderly Waiver Program?
Yes
No
Clear selection
Are you part of the Alternative Care Program?
Yes
No
Clear selection
Do you receive SSDI or SSI benefits?
Yes
No
Clear selection
Please list any other programs currently providing services to help you stay in your home.
Your answer
Do you have a case manager/social worker?
Yes
No
Clear selection
If yes, please provide name & phone number.
Your answer
Emergency Contact (name, relationship, & phone number)
*
Your answer
Services Interested In (check all that apply)
*
Companionship/Friendly Visit
Reassurance Phone Calls
Light Housekeeping
Odd Jobs/Home Repairs
Transportation
Shopping/Errands
Respite Care
Laundry
Heavy Cleaning/Organization
Outdoor Chore
Other:
Required
I certify that they above information is accurate and I give my consent for Faith in Action of Dodge County to conduct a routine background check.
*
Your answer
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