Enrollment Form - Agency on Aging Area 4 Concierge Care Program

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Caring for a loved one (e.g., family member, friend, or neighbor) can be tough to navigate alone. Our team is ready to help you find a solution to realistic care and support for your loved one. Please complete the intake form below with information about you and the person you care for. This information will help us know how we can assist you. If you would like help completing this form, please call us at 1-800-211-4545 Monday to Friday from 8:30am-4:30pm PST.

Upon completion of this enrollment form, you will gain access to the Care 4 Caregivers program. You will receive weekly text messages with helpful information and guidance from our team straight to your phone. Text messages will come from the number 43386. We suggest saving this number as a contact in your phone with the name “Care 4 Caregivers.” You can review the Terms and Conditions here: https://c4c.gomohealth.care

In addition to the text messages, you will also receive access to the Care 4 Caregivers Library of caregiver resources, customized with information to meet your unique needs.

Please take a few minutes to answer the following questions about you or the primary caregiver signing up today. We want you to know that all information shared and received in our program is confidential. Your information will not be shared or used for any other purpose.

Caregiver Name:*

First Name Last Name

Cell phone number:*

Caregiver’s Email Address:*

Caregiver’s County:*

Note: To qualify for this program, you and/or the person you care for must reside in the following counties: Sacramento, Placer, Yolo, Yuba, Sutter, Nevada, Sierra

Caregiver Ethnicity:*

Alaska Native

American Indian

Asian

Asian Indian

Cambodian

Chinese

Filipino

Japanese

Korean

Laotian

Vietnamese

Other Asian

Black or African American

Hispanic or Latino

Native Hawaiian/Other Pacific Islander

Guamanian

Hawaiian

Samoan

Other Pacific Islander

White

Prefer not to disclose

Caregiver’s age:*

Please provide some additional information about the person you care for.

Name of the person you care for:*

First name of the person you care for Last name of the person you care for

County of residence of the person you care for:*

Note: To qualify for this program, you and/or the person you care for must reside in the following counties: Sacramento, Placer, Yolo, Yuba, Sutter, Nevada, Sierra.

Looks like you are not eligible to continue in this program. Please click Submit to end this form.

How old is the person you care for?*

60 years old or older

Less than 60 years old

What has the person you care for been diagnosed with?*

(Select all that apply)

Alzheimer’s disease

Mild cognitive impairments 

Traumatic brain injury

Vascular and mixed dementia 

Parkinson’s disease

Huntington’s disease

Other

None

You chose "Other", please specify:*

Is the care recipient on Medi-Cal? *

Yes

Is their Medi-Cal through Health Net, Kaiser, Partnership, or Anthem?*

Health Net

Kaiser

Partnership

Anthem

Not sure

None of the above

Are they a recipient of In-Home Supportive Services (IHSS) through Medi-Cal?*

Yes

Does the person you care for need help with any of the following?*

Feeding

Dressing

Bathing

Toileting

Transferring (i.e., in and out of a chair)

Walking

None

In the last 3 months, has a lack of reliable transportation kept the person you care for from medical appointments, meetings, work, or from getting things needed for daily living?*

Yes

In the last 3 months, did the person you care for ever eat less than you felt s/he should because there wasn’t enough food at home or money for food?*

Yes

How many times in the past three months did the person you care for visit an emergency room without being hospitalized?*

How many times did the person you care for stay in a hospital overnight or longer in the past three months?*

How many nights in total did your care recipient spend in the hospital?*

To better help you, please tell us a little bit more about how you are feeling as a caregiver:

On a scale of 1-10, how would you rate your stress level?*

(1 = no stress, 10 = very high stress)

As the primary caregiver, where does the source of your stress come from?*

Caregiving responsibilities

Something other than caregiving

Both

Over the last 2 weeks, how often have you been bothered by the following problems?

Little interest or pleasure in doing things:*

Not at all

Several days

More than half the days

Nearly every day

Feeling down, depressed, or hopeless:*

Not at all

Several days

More than half the days

Nearly every day

Hidden

PHQ2_Score

Do you need a break from caregiving or need respite care?*

Yes

Do you already have paid help?*

Yes

Is the person helping you connected with an agency?*

Yes

What is the name of the agency?*

What is the telephone number of the agency?

Who is providing your respite care?*

Do you need help with Medicare or have questions on Medi-Cal eligibility?*

Yes

Are there other concerns you wish to speak to us about? If so, please note them here:

Terms and Conditions*

The Telephone Consumer Protection Act generally requires us to obtain consent before contacting people on their mobile phones. By enrolling in this program, you are granting consent to GoMo Health to contact you via text message to the number you are enrolling with from the number 43386. You may get up to 12 messages per week. Please note that depending on your mobile phone service plan, message and data rates may apply according to your mobile provider. You also confirm that you are the wireless subscriber or owner of the mobile number provided and have the authority to provide consent. For help, please text HELP to 43386. You may opt-out at any time by replying STOP or STOPALL to 43386. To unsubscribe from emails, click “unsubscribe” at the bottom of any email you receive. Terms & Conditions can be found at https://c4c.gomohealth.care. GoMo Health Privacy Policy can be found here: https://gomohealth.com/privacy/.

I have fully read and agreed to the terms and conditions of this program.

I have completed the enrollment form, provided electronic consent to enroll, and I grant permission to GoMo Health to contact my cell phone via text message from the phone number 43386.