Virginia Caregiver - Service Form

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VIRGINIA CAREGIVER – SERVICE FORM
Today’s Date
______/______/________
Updated
______/______/________
Caregiver Name & Demographic Information
Caregiver’s Name: _________________________________________________________________________
(Last)
(First)
(Middle Initial)
Address:
______________________________________________________________________________
(Street)
(Apartment Number)
______________________________________________________________________________
(City)
(State)
(Zip)
Phone: _(_____)____________________
County/City of Residence: __________________________
Caregiver’s Customer ID: ___________________________
Caregiver’s Birthdate: ______/______/______
Caregiver’s Gender:
______ Male
______ Female
(Month)
(Day)
(Year)
Caregiver’s Race and Hispanic Status:
American Indian or
____
____
____
White or Caucasian Only
Black / African American Only
Alaskan Native Only
Native Hawaiian or
____
____
____
Asian Only
Pacific Islander Only
Some other Race Only
_____
Hispanic or Latino Origin OR
____
____
_____
Two or More Races Combined
Race unknown or unreported
Not Hispanic or Latino Origin OR
_____
Hispanic ethnicity unknown
Caregiver’s Relationship to Care Receiver:
____
Husband (Spouse)
____
Wife (Spouse)
____
Son
____
Daughter
____
Other Relative (e.g. Parent, Sibling)
____
Grandparent
____
Non-Relative
____
Non-Relative Legal Guardian or Custodian
____
Does Caregiver Live with Care Receiver?
Yes
____
No
NOTE: Care Receivers 19 to 59 years of age must have a severe disability as
Care Receiver Information
defined in Section 102(48) of the OAA or a diagnosis of early onset dementia.
Care Receiver’s Name: ______________________________________________________________________
(Last)
(First)
(Middle Initial)
Care Receiver’s Customer ID: _______________________
Care Receiver’s Birthdate: _____/_____/______
(Month) (Day) (Year)
For Office Use Only
Services Requested: _______________________________________________________________________
________________________________________________________________________________________
Services Provided: ________________________________________________________________________
________________________________________________________________________________________
Agency / Provider: _____________________________________________ PSA No. __________________
NOTE: At a minimum, this form must be updated annually in order for a care receiver/caregiver to continue service.
Virginia Department for the Aging
vda.virginia.gov
Revised 5/20/2010

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