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English (US)
Screening for Family Caregiver Reimbursement Program
This program is offered through the Arizona Department of Economic Security. When you submit this form to the Arizona Caregiver Coalition, we will let you know if you meet requirements and are eligible to submit an application.
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Language other than English?
Spanish only
What is your status
Family Caregiver, caring for a family member
Person over 60 (not a caregiver, but perhaps you have a caregiver)
Agency / Professional
Friend, neighbor
What is your relationship to the person you care for?
spouse / domestic partner
son / daughter (in law)
parent
sibling (brother, sister, step/adoptive)
Other relative
How did you hear about us?
Internet search
Facebook
Family member
Agency
Friend/Neighbor
DES/DAAS
DES/DDD
Media, news, radio
AAA
AARP
Please answer all these screening questions.
If you answer "no" to any questions or are not sure, you may still submit the form but you may not be eligible at this time.
You (caregiver) and your family member
Yes
No
Are you a family caregiver?
Is this the first time you are applying?
Is your family member 18 years or older?
Are you and your family member Arizona residents?
Does your family member require assistance with one or more activities of daily living (toileting, bathing, dressing, grooming, eating, mobility, or transferring)?
Does your income meet these income criteria?
Your income and your family member's income must be $75,000 or less in total income
OR
As a couple, you must earn less than $150,000 per year in total income including the family member's income)
Your project or purchase
Yes
No
Still planning to do it
Did or will the home modification or purchase of assistive technology occur on or after January 1, 2020?
Do you have receipts for the home modification or assistive care technology dated on or after January 1, 2020?
Did you modify or make changes to your home or purchase assistive technology for your family member?
Preferred communication by:
Phone
E-mail
Mail
For office use; leave blank (action)
Sent application by mail
Sent application with link by e-mail
Not eligible
Need to follow-up
For office use; leave blank
CR under 18
There is no caregiver
Can't afford to pay
Income too high
CR deceased
Comments
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