• Caregiver Waiver Eligibility Screening Questionnaire Form

    Please complete this brief screening to help determine eligibility for caregiver waiver programs. All questions are required.
  • Does the care recipient live with you?*
  • Are you a U.S. citizen or permanent resident?*
  • Do you currently receive any government or state caregiving benefits?*
  • Are you currently employed?*
  • Do you have additional support for caregiving (family, friends, paid help)?*
  • Are you willing to participate in a more detailed eligibility assessment if required?*
  • Should be Empty:
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