Global Blessing, Inc.
2417 Canton Road, Marietta, Ga 30066
globalblessinginc@myglobalblessings.com
www.myglobalbelssings.com
(470) 813-4339
Caregiver Wellness Program Assistance Application
APplication details:
This application is to determine eligibility for the Caregiver Wellness Program. For program details, visit out website at www.myglobalblessings.com/our-services. For any additional questions, email info@myglobalblessings.com.
Personal Information
Use this section to provide contact details.
Full Name of individual filling out the form
*
First Name
Last Name
Full Name of senior receiving care
*
First Name
Last Name
Age Group of senior
*
Less than 55 years old
55-64 years old
65+ years old
Social Security Number
*
Format: {xxx-xx-xxxx}
Gender
*
Please Select
Male
Female
Non-binary
Transgender Male
Transgender Female
Not Applicable
Other
Relation to senior receiving care
*
Child
Spouse, Partner
Parent
Friend
Other
If other, please specify
Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Best Phone Number to Contact
*
Best E-mail
*
example@example.com
Back
Next
Survey of Care
Please fill out this short survey, so we can better understand the amount of care provided for the senior by the individual providing the informal caregiving.
How often do you provide care for the senior in question?
*
Full-time (Every day)
Part-time (At least half the month)
Occasionally (At least a third of the month)
Rarely (Less than 7 days a month)
Do you provide care alone or with assistance?
*
No assistance
Light Assistance
Some Assistance
Full assistance
If you receive assistance with the care of the senior, where is the assistance coming from and how often?
Ex: hospice care, home health, family assistance, etc.
Can the senior in question assist with activities of daily living or require full assistance
*
Can assist in all activities
Needs some assistance
Needs full assistance
Is the senior in question able to answer for themselves regarding wants, needs, or pain level
*
Yes
No, further explanation provided
If no to the above question, please detail any impediments they may have that would make them incapable of answering for themselves.
Ex: general weakness, mute, Dementia/Alzheimer's, cognitive limitations, etc.
Is the senior in question able to walk
*
Yes, without assistance
Yes, with assistance of a walker
No, wheelchair bound
No, bed bound
Back
Next
Care Facility Details
Please fill out the form to let us know which care facility the senior in question would be receiving short-term care along with the duration of stay.
Name of Care Facility
*
Type of Care Facility
*
Nursing Home
Assisted Living
Personal Care Home
Other
If other, please specify
Address of Care Facility
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type of Stay
*
Day-care (only during working hours)
Respite (overnight)
Mixed
Other
If other, please specify
Daily Rate at Care Facility
*
Expected Duration of Stay
*
Phone Number of Care Facility
*
Please enter a valid phone number.
Full Name of Point of Contact at the Care Facility
*
First Name
Last Name
Title of Point of Contact
*
E-mail Address
*
example@example.com
Website, if applicable
Back
Next
Documents
Please attach a digital copy of a document proving financial or care responsibility over the senior in question. Acceptable documents may include but are not limited to: Power of Attorney Form, Tax Form showing claim of elderly individual as a dependent, Witness Testimony (must be someone other than a family member).
File Upload
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Additional File, if needed
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Additional File, if needed
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Back
Next
Additional Comments
How did you hear about us?
*
Please Select
Newspaper
Internet
Magazine
Other
Please Specify
Please provide further comments in the space below:
Submit
Should be Empty: