Caregiver Intake Form

1

Personal Information* This field is required.

Name

Please enter your email

Please enter your phone

2

Are you 21+?* This field is required.

YESNO

3

Birthday* This field is required.

Date

4

Do you have Medicaid?* This field is required.

Yes

No

6

What are your current top priority needs?* This field is required.Needs can include anything from Health, Wellness, Financial or Mental Health. There is no right or wrong answer.

7

What is your biggest passion, talent, hobby, skill or interest?* This field is required.

8

Highest Level of Education* This field is required.

High School Diploma or Equivalent

Bachelor's Degree

Some College

Master's Degree

PHD

9

Are you Employed?* This field is required.

YESNO

10

If employed, have you been with the same employer for at least 6 months?

YESNO

11

Is your household income less than $23k/year?* This field is required.

YESNO

12

Have you ever been diagnosed with a mental health illness?* This field is required.

YESNO

13

What is your mental health diagnosis or illness?

14

Have you ever been hospitalized due to mental illness?

YESNO

15

Have you ever been enrolled in a crisis program?

YESNO

16

Have you ever been incarcerated?* This field is required.

YESNO

17

Have you ever been prescribed any mental health medications?* This field is required.

YESNO

18

Are you a cannabis user?* This field is required.

YESNO

19

Do you think you should be medically recommended for cannabis use?* This field is required.

YESNO

20

Would you like access to have our Community Champion Caregiving Growers to personally share their exclusive harvests with you?* This field is required.

YESNO

21

Are you interested in being trained as a Caregiver to support peers with overcoming similar situations?* This field is required.

YESNO

22

Who referred you? * This field is required.* Name of person/organization enrolling you?