Structured Family Care Eligibility Form

1

Name of Caretaker* This field is required.

First Name

Last Name

2

Phone Number* This field is required.

Please enter a valid phone number.

3

Email* This field is required.

example@example.com

5

Do you currently live with the person you care for?

YESNO

6

Do you provide daily care and support?

YESNO

7

Are you currently being paid by another caregiving program?

YESNO

8

Care Recipient's Name

First Name

Last Name

9

Does this person have active Indiana Medicaid?

YESNO

11

Does this person live in a private home (not a facility)?

YESNO

12

Does the care recipient have a primary care provider (PCP)?

YESNO

13

Are you willing to participate in training and home visits?

YESNO

14

When would you like to start?

Immediately

Within 1 Month

Just Exploring

15

Preferred Contact Method

Call

Text

Email

No Preference