To apply for the Dementia Caregiver Assistance Program, please fill out the application below.  You will be notified within 10 business days on the status of your application and with next steps.

 

Caregiver Assistance Program Application

  • Date Format: MM slash DD slash YYYY
  • Caregiver Information

    Please note ALL information must be filled out completely or application cannot be processed.
  • Care Recipient Information

    Person Living with Dementia, Alzheimer's Disease, etc.
  • Needs Assessment

  • Please describe need for services indicated in question above. Please describe in detail your specific need for services and a break down of cost. Questions to consider: Why do you need care at this time? Why do you need a break? What has changed in your personal situation that there is a need for short term assistance?
  • *Please note this does not guarantee the full amount will be funded. Please include type of service, the cost for service, how many days, hours, and rate.
  • Dates of Service

    Please note all funds must be used within 90 days of application approval.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Agency Info

    If you already have an agency or caregiver lined up to help with your loved one, please provide information here. If you need assistance finding someone, please indicate in the first blank under Person or Agency.
  • Qualification