• Pre-Screening Eligibility Form

    Family Caregiver Program Overview

  • Before proceeding, please review the information below:

    Caregiver Eligibility

    • Adult children, relatives, friends, and other qualified individuals may be eligible.
    • Parents of minor children generally cannot be the paid caregiver.

  • Required Documents
    Depending on your situation, you may be asked to provide:

    • Medicaid Care
    • Physician Information
    • DMAS-7
    • UAI
    • Insurance Information

  • Assessment Fees

    • PCA Assessment: $125
    • Non-PCA Assessment: $200
    • No payment is collected upfront.

    If approved and hired, the fee is deducted over four pay periods.

    If the case is not approved, Golden Connections Home Care absorbs the cost.

  • Next Steps

    1. Complete this application.
    2. Check your email for additional instructions.
    3. Our team will review your information.
    4. Required documents will be collected.
    5. Authorization will be submitted.
    6. Caregiver onboarding begins upon approval.

  • Family Caregiver Pre-Screening Application

    Please complete the information below. Once submitted, a member of our team will review your application and contact you regarding the next steps.
  • Format: (000) 000-0000.

  • Caregiver Information
    (Eligibility requirements vary based on the care recipient's age, Medicaid program, and individual circumstances. Parents of minor children may be eligible in certain cases. Please contact our office for more information and a personalized eligibility review.)

  • Caregiver's Date Of Birth*
     - -
  • Format: (000) 000-0000.
  • What is the age group of the care recipient?*
  • Does the Prospective Caregiver Currently Hold a PCA Certificate? (A PCA certificate is not required to apply. Additional training requirements may apply depending on program eligibility.)*
  • Is the Prospective Caregiver Willing to Complete a Criminal Background Check?*

  • Care Recipient Information

    Please provide information for the individual who will be receiving care services.
  • Care Recipient's Date of Birth*
     / /
  • Does the Care Recipient Reside in the Same Household as the Prospective Caregiver?*
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  • Emergency Contact Information

    Please provide the contact information for an emergency contact who is not the parent/guardian or prospective caregiver.
  • Format: (000) 000-0000.
  • Applicant Acknowledgment*

  • What Happens Next?

    Thank you for submitting your pre-screening application.

    After submission:

    1. You will receive a confirmation email.
    2. Our intake team will review your information.
    3. Additional documents may be requested.
    4. We will contact you regarding eligibility, next steps, and any required assessments.
    5. If eligible, we will assist with the authorization and onboarding process.
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