Caregiver Intake Form

~~~Verification documentation is required before applying ~~~

Please have one of the following ready to upload

• DD214

• VA or DoD ID

• VA Benefits Award Letter

• VA Caregiver Award Letter

~~~

For Financial Assistance requests, please also upload (as applicable):

• Statements

• Bills/Invoices

• Estimates/Quotes

Vendor Requirements:

• A completed W-9 is required from each vendor/company we will pay directly. ( A W-9 is an IRS form used to collect a business’s or individual’s tax identification information (such as name, address, and EIN or SSN) so that an organization can legally issue payment and report it to the IRS if required)

Should you have trouble accessing these documents, please reach out to us here:ResourceNavigation@elizabethdolefoundation.org

Privacy Notice:

The information collected in this form is used internally only to help us better understand and serve our community. This information will not be shared, sold, or used outside of our organization, and your individual responses will remain confidential. Please see our privacy policy for additional information.

What is your role?(Required)

If your role falls outside of the above categories, please refer to our Resources for Veterans page for assistance.

Who referred you?(Required)

If you answered 'other', please specify:

Please tell us about yourself:

Name(Required)

First Last

Email(Required)

Address(Required)

Street Address City State ZIP Code

Phone(Required)

Have you ever served in the military?(Required)

If you have served in the military, please select your era of service:

What is your military prefix?

Demographic Information

Your answer will not affect your eligibility or application status. We use this only to connect you with the right resources.

What is your gender?(Required)

What is your date of birth:(Required)

What is your racial and/or ethnic background:(Required)

Highest grade completed in school:(Required)

Some High School

High School Graduate

Some College

Technical School / Trade School

Associates Degree

College Degree

Post Graduate Degree

None

Caregiving Information

On average, how many skilled care hours are provided per day?(Required)

Skilled care is medical care by licensed nurses (e.g., wound care, IVs, medication management) under a doctor’s plan.

On average, how many non-skilled care hours do you provide per day?(Required)

(Help with daily activities (bathing, dressing, meals, housekeeping); no medical procedures.)

Are you currently enrolled in the VA Program for Comprehensive Family Caregivers (PCAFC)?(Required)

Please select any chronic conditions or diagnoses you yourself are managing (if applicable):

Do you live with your care recipient (the person you're caring for)?(Required)

What year did you start caregiving?(Required)

Please rate your level of stress:

In the past month, how often have you felt you lacked control over important parts of your life as a caregiver?(Required)

In the last month, how often have you felt confident about your ability to handle your personal challenges?(Required)

In the last month, how often have you felt that things were going your way?(Required)

In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?(Required)

The following question relate to your care recipient.

What is your care recipient's full name?(Required)

What is your care recipients date of birth?(Required)

What is your care recipient's gender identity?(Required)

What is your care recipient's racial/ethnic background?(Required)

What is your care recipient's era of service?(Required)

Pre-9/11

Post-9/11

Both

What (if any) chronic conditions does your care recipient currently suffer from?(Required)

Please list any additional chronic conditions or diagnoses your care recipient are managing?

What is your relationship to the care recipient?(Required)

The following question are for Survivors:

Cause of Death:(Required)

Are you receiving survivor benefits (DIC, SBP, etc.)?(Required)

Yes

The following questions asks about your Fallen Service Member or Veteran.

What was your Fallen Service Member or Veteran's full name:(Required)

What was your Fallen Service Member or Veteran's date of birth?(Required)

What was your Fallen Service Member or Veteran's race/ethnicity?(Required)

What was your Fallen Service Member or Veteran's gender identity?(Required)

What was your Fallen Service Member or Veteran's era of service?(Required)

Pre-9/11

Post-9/11

Both

The following questions concern your Active-Duty service member.

What is your Active-Duty service member's full name?(Required)

What is your Active-Duty service member's current duty station?(Required)

What is your Active-Duty service member's date of birth?(Required)

What is your Active-Duty service member's race/ethnicity?(Required)

What is your Active-Duty service member's era of service?(Required)

Pre-9/11

Post-9/11

Both

What is your relationship to your Active-Duty service member?(Required)

Need Request

In which areas do you need support or assistance?(Required)

If you answered, 'Other', please elaborate:

Please describe your need support or assistance?(Required)

Over the past 12 months, have you received support or assistance from other organizations? If so, please list the organization(s) and service(s) they provided.

Your answer will not affect your eligibility or application status. We use this only to connect you with the right resources.

Please upload your verification document here:(Required)

Max. file size: 256 MB.

Verification required before applying. Please have one of the following ready to upload ( should you have trouble accessing these documents, please reach out to us here: ResourceNavigation@elizabethdolefoundation.org): • DD214 • VA or DoD ID • VA Benefits Award Letter • VA Caregiver Award Letter

Financial Wellness Questions

You shared in your application that financial assistance is an area of need for you and your family. The Elizabeth Dole Foundation has partnered with the Bob and Dolores Hope Foundation to provide financial assistance to military and veteran caregivers like you to help get back on track. To apply we’ll need a copy of documentation, such as a current bill, statement, or invoice. If your request is approved, we will then ask that you provide a W-9 from the vendor so that we can issue payment to the vendor directly on your behalf.

Type of Assistance Requested(Required)

Reason for Request(Required)

Total Amount Requested(Required)

Annual Household Income(Required)

Under $20,000

$20,001-$40,000

$40,001-$60,000

$60,001-$80,000

$80,001-$100,000

$100,001-$150,000

Over $150,000

Please provide the total yearly income for your household. This should include wages, salaries, pensions, disability benefits, Social Security, VA benefits, and any other sources of income for all household members.

Current Statement or Bill(Required)

Max. file size: 256 MB.

A recent utility bill, rent invoice, mortgage statement, or other document showing the amount due. Requests for medical bills will only be accepted for care provided by a VA or DoD medical facility or a reputable private medical provider; assistance will not be provided for experimental, alternative, or unconventional healthcare (i.e., massage, homeopathy, reiki, meditation).

W9 Form(Required)

Max. file size: 256 MB.

A W-9 is a U.S. IRS form that provides vendor name, address, and taxpayer ID so we can process payments and, if required, issue tax forms (e.g., a 1099). EDF requires that you secure a W9 from the vendor/ landlord/ organization.

Lease Agreement or Eviction Notice

Max. file size: 256 MB.

Invoice or Estimates

Max. file size: 256 MB.

Additional Document Upload

Max. file size: 256 MB.

Additional Document Upload

Max. file size: 256 MB.

Untitled(Required)

By submitting this form, I agree to the Terms of Use and Privacy Policy.

Caregiver Intake Form

Privacy Notice:

Please tell us about yourself:

Demographic Information

Caregiving Information

Please rate your level of stress:

The following question relate to your care recipient.

The following question are for Survivors:

The following questions asks about your Fallen Service Member or Veteran.

The following questions concern your Active-Duty service member.

Need Request

Financial Wellness Questions

Submit