Grant

Provider  *	Please pick one Elderhouse Inc Fairfield County House Inc Family and Childrens Agency Hall Senior Center Westport Center for Senior Activities Town of Monroe Town of Trumbull SWCAA
Grant Name  *

Care Recipient

Recipient First Name  *
Recipient Last Name  *
Recipient Gender  *	Please pick one Female Male Non-Binary Other
Recipient Marital Status  *	Please pick one Married Widowed Civil Union Divorced Separated Single
Primary Language*	Please pick one Arabic American Sign Language Albanian Bengali Cambodian Cantonese Chinese Haitian/Creole Danish English Farsi French German Gujarathi Greek Hindi Italian Japanese Korean Kru, Ibo, Yoruba Mandarin Hungarian Patois Romanian Serbo-Croatian Tamil Telegu Portuguese Polish Russian Spanish Tactical Sign Language Turkish Ukrainian Urdu Vietnamese Other
Recipient English Proficiency  *	Please pick one Very Well Well Not well Not At All
Recipient Date of Birth (MM/DD/YYYY)  *
Recipient Phone (###-###-####)  *
Recipient Street  *
Recipient City  *
Recipient State/Province  *
Recipient Zip  *
Has Alzheimer’s Disease or a Related Dementia	Please pick one None Early Onset Dementia Mild Moderate Severe unknown
Is Disabled and Under 60:
Recipient Ethnicity  *	Please pick one Hispanic/Latino Not Hispanic/Latino
Recipient Race *	Please pick one White Black/African American Asian American Indian/Native Alaskan Native Hawaiian/Other Pacific Islander
Their Individual Income is About:	Please pick one Under $1,304 (100%) $1,305 - $1,630 (125%) $1,631 - $1,956 (150%) $1,957 - $2,282 (175%) $2,283 - $2,608 (200%) $2,609 or over (over 200%)
They Live With Their Spouse and Both of Their Income Is About:	Please pick one Under $1,763 (100%) $1,764 - $2,203 (125%) $2,204 - $2,644 (150%) $2,645 - $3,084 (175%) $3,085 - $3,525 (200%) $3,526 or over (over 200%)
Recipient Living Arrangements  *	Please pick one Alone With Spouse With Unmarried Partner With Spouse/Partner and Child/Children With Child, No Spouse With Grandchildren With Other Relatives With Others
Recipient Housing  *	Please pick one Private Home Private Apartment Senior Housing Congregate Housing Public Housing Nursing Home Residential Care Home Assisted Living Other
Recipient Needs Help With the Following Activities (select all that apply)	Eating Dressing Bathing/Washing Using Toilet Getting Out of Bed/Chair Continence
Recipient Needs Help With the Following Activities (select all that apply)	Planning/Preparing Meals Shopping Managing Money Using Telephone Housekeeping Doing Laundry Taking Medicine Using Transportation

Nutritional Risk- Select All that Apply

Has Illness/Condition That Changed Eating Habits*	--None-- Yes No
Eats Fewer Than 2 Meals A Day*	--None-- Yes No
Eats Few Fruits and Vegetables or Milk Products*	--None-- Yes No
Has Problem Chewing/Swallowing*	--None-- Yes No
Doesn't Have Enough Money/Food Stamps To Buy Food*	--None-- Yes No
Takes 3+ Medications*	--None-- Yes No
Eats Alone Most of the Time*	--None-- Yes No
Has 3+ Alcoholic Drinks A Day*	--None-- Yes No
Without Wanting to, Has Weight Change of 10 Pounds*	--None-- Yes No
Not Able to Shop/Cook/Eat independently*	--None-- Yes No

Caregiver

Caregiver First Name  *
Caregiver Last Name  *
Caregiver Gender*	Please pick one Female Male Non-Binary Other
Caregiver Relationship  *	Please pick one Brother Daughter Daughter-in-Law Domestic Partner Father Husband Grandfather Grandmother Granddaughter Grandson Mother Non-Relative Other Relative Sister Son Son-in-Law Wife
Caregiver Date of Birth  *
Caregiver Ethnicity*	Please pick one Hispanic/Latino Not Hispanic/Latino
Caregiver Race  *	Please pick one White Black/African American Asian Native American/Alaskan Native Native Hawaiian/Pacific Islander Other
Caregiver Phone (###-###-####) *
Mobile Phone
Email
Caregiver Address Same As Care Recipient?
Caregiver Street (Only if addresses do not match)
Caregiver Town (Only if addresses do not match)
Caregiver Zipcode (Only if addresses do not match)

Confirm Form 5

Provider & Grant Name  *
Additional Comments