Caregiver Intake Form

This agreement outlines the expectations, roles, and responsibilities between you and your coordinator throughout the resource coordination process. We are dedicated to making each Caregiver’s experience with us as positive and productive as possible, but we can’t achieve this without your cooperation. Together, we will work as a team to ensure successful coordination. Caregiver agrees to the following responsibilities: 1. Honest and Accurate Information: I will provide honest and accurate information to the best of my ability and knowledge. 2. Documentation: I will provide appropriate documentation as requested to facilitate assistance. Examples of such documentation may include: – Proof of Service: DD214 or LES – Disability Statement: Letter from the Department of Veterans Affairs, PCAFC approval letter, bills, eviction notice, etc. 3. Active Participation: I will actively participate and stay engaged throughout the coordination process. For example: – Timely Communication: I will return phone calls and emails in a timely manner. – Collaborative Planning: I will work together with my coordinator to establish a plan going forward. – Resource Follow-through: I will make every effort to follow through with the resources my coordinator provides and report back the results in a timely manner. – Respectful Communication: I will be respectful and courteous in all communications with my resource coordinator(s).