CaringKind Connection - Special Assistance Funds

CaringKind Connection - Special Assistance Funds
CaringKind offers Care Partners who are active clients of the organization the opportunity to apply for Special Assistance Funds. An active client is one who takes advantage of the organization’s programs and services for the benefit of themselves and the Person Living With Dementia. Eligibility is based on need; the following information is needed to apply:
- Demographic information for both the care partner and person living with dementia
- Monthly income and expenses for person living with dementia
- Long term plan – What is the long-term plan to ensure the person living with dementia’s needs will be met after the the funding is completed?
Special Assistance Funds awarded by CaringKind can be used to offset the cost of respite, wandering prevention items, or medical equipment/ supplies. Maximum award is $2000 and expire 12 months from the date they are issued. Grants are vendorized – CaringKind pays the vendor directly, Care Partners will not be reimbursed. Grants cannot be used for services provided prior to the award date.

If interested in applying, please complete the form below to be connected to a CaringKind Navigator.
Type of Assistance Requested:
If Other, please specify:
Please share details regarding the need for assistance:
CARE/SUPPORT PARTNER
Relationship to Person with Dementia
Care/Support Partner Name

First NameLast Name
Care/Support Partner Email
If your client does not have an email account please use the format below and insert their real name: FirstName.LastName@noemail.com (e.g. John.Doe@noemail.com)
Care/Support Partner Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address (Care/Support Partner)
City (Care/Support Partner)
State (Care/Support Partner)
Zip (Care/Support Partner)
Preferred Language
Military Status (Care/Support Partner)
Year of Birth (Care/Support Partner)
Please enter 4 digits.
Gender (Care/Support Partner)
Ethnicity (Care/Support Partner)
Race (Care/Support Partner)
household
CP Account Name
PERSON LIVING WITH DEMENTIA
PWD Name

First NameLast Name
Diagnosis
Date of Diagnosis

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
PWD Email
If the PWD does not have their own unique email account (e.g. uses their carepartner's email) please use the format below for the PWD inserting their real name: FirstName.LastName@noemail.com (e.g. John.Doe@noemail.com)
PWD Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
PWD Year of Birth
Please enter 4 digits.
PWD Military Status
PWD Gender
PWD Ethnicity
PWD Race
Living Situation
Address (PWD)
City (PWD)
State (PWD)
Zip (PWD)
PWD Account Name
Consent
I give permission to CaringKind and the service provider below to exchange contact and health information for the person with dementia and/or care/support partner named above in order to provide dementia education, information and support related to the coordination of care. I understand that a CaringKind Specialist will contact me about services and programs that are available. I understand the contact and health information provided will not be disclosed or shared with any other entity unless authorization from the listed parties is obtained. I understand this permission can be revoked at anytime by contacting CaringKind and/or the referring provider named below.
Signature (To be signed by the person to be contacted)
Care Partner/ Person with Dementia provided verbal consent to provider below.
Date of Consent / Referral

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
TO BE COMPLETED BY REFERRING PROVIDER:
Referring Person Full Name

First NameLast Name
Agency
Referring Person Email
A copy of this form will be sent to your email.
RecordType ID
Form ID
Case Note Desc
Account Name Final
Final Address
Final City
Final State
Final Zip
Should be Empty:

CaringKind Connection - Special Assistance Funds

CARE/SUPPORT PARTNER

PERSON LIVING WITH DEMENTIA

Consent

TO BE COMPLETED BY REFERRING PROVIDER: