Name of Family Member Receiving Care * First Name Last Name Date of Birth MM DD YYYY Gender Male Female Phone Number * (###) ### #### Address City State (Only Georgia Residents Qualify) Georgia Zip Code County Email Georgia Medicaid Number (if known) Please check any of the medical conditions you may have. Dementia Stroke Congestive Heart Failure Renal Failure Osteoarthritis Rheumatoid arthritis Diabetes COPD Amputation Spinal Cord Injury Brain Injury Back pain Other Please check the activities you need help with. Bathing Dressing Going to the bathroom Walking Eating Other Do you need at least 5 hours of help, 7 days a week? Yes No Do you get a social security disability payment? Yes No Message Name of Caregiver First Name Last Name Email of Caregiver * Phone Number of Caregiver * (###) ### #### How are you related to the family member you are providing care for? * Please note spouses and legal guardians do not qualify. The caregiver is a child. The caregiver is a niece/nephew. The caregiver is an uncle/aunt. The caregiver is a sibling. The caregiver is a parent. The caregiver is a spouse. Do you have a job outside of being the caregiver? Yes No Are you at least 18 years old? Yes No Do you live in the same household as the family member you are caring for? Yes No Please include any additional information below: Thank you for completing the first step to seeing if you qualify to be paid as a caregiver. We will be in touch shortly! Referral Form
