To be considered for the Caregiver Coaching Program, all questions on this form must be answered.
1) Caregiver Coaching Program Readiness to Participate
Please answer these questions to determine your readiness to participate in the Caregiver Coaching Program. If you feel you are not ready to commit to this program now, you may wish to view our other service options: https://ontariocaregiver.ca/for-caregivers/ OR come back to this form in the future when you are ready.
If you are completing this registration on behalf of someone else, you must attain their verbal permission and they must be informed of the following:

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* 1. Coaching sessions are limited up to six 1-hour sessions within a 3-month period. All sessions are either provided by telephone or Zoom. Your first 3 sessions will occur weekly to establish immediate support while the remainder of your sessions can be scheduled with flexibility during the 3-month period. It is important to make these sessions a priority as we reserve these spots for caregivers in advance. Are you ready to commit to a coaching relationship knowing the time involved?

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* 2. Coaching sessions require accountability from participants, where mutually agreed upon action steps or homework will need to be accomplished to the best of your ability (e.g., follow-up on a resource, application of self-care and/or communication strategies etc.). Are you ready to be accountable to a Caregiver Coach?

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* 3. The Caregiver Coaching Program requires an intake screening (up to 30-minutes), where you will be asked questions related to your well-being over the telephone. These assessments ensure our Caregiver Coaches can design sessions that suit your unique caregiving needs. The same questions will be asked at the end of the program. Are you comfortable to engage in an intake screening as well as a post-program assessment?

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* 4. Coaching is not to be used as a substitute for counseling, psychotherapy, psychoanalysis, or any form of mental health care. Thinking about your needs, are you comfortable to access a coach knowing they are not a counsellor or psychotherapist?

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* 5. I reside within Ontario.

2) If you feel like you are ready to participate in the Caregiver Coaching program after answering "yes" to all of the questions above, please continue and provide the following information:
Personal Contact Information

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* 6. First name

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* 7. Last name

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* 8. Postal code

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* 9. What Pronouns do you use? For example: she/her, he/him, they/them

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* 10. What days or times are the best to reach you by phone? (e.g., mornings, evenings etc.)"

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* 11. Phone Number

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* 12. Email Address

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* 13. Consent For Us to Share This Information. You agree that we may share the information provided with OCO’s Caregiver Coaches. You also agree that we may share this information with other relevant OCO staff or volunteers (such as a Peer Mentor) as discussed and agreed to with your Caregiver Coach (e.g., you may wish to participate in a warm-transfer into the 1:1 Peer Support Program from the Caregiver Coaching Program).

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* 14. I am completing this registration on behalf of someone else and have attained their verbal permission. The registrant has agreed to the terms outlined above.

If you are completing this registration on behalf of someone else and have attained their verbal permission, please include your information below.

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* 15. Name of person completing the form on behalf of registrant

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* 16. Email or phone number of person completing the form on behalf of registrant

Your Caregiver Role

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* 17. How long have you been caregiving for?

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* 18. Do you currently live with the person you care for?

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* 19. What is your current caregiving situation? (i.e., who are you caring for, for how long, if you live with your care recipient, their conditions, etc.)

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* 20. How are you feeling about your caregiving role?

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* 21. What is currently the biggest challenge in your caregiving role?

4) Demographics. OCO would like to better understand who we are currently reaching with our programs and services. To help us know more about you, please answer the following questions:

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* 22. How old are you?

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* 23. What term(s) do you use to describe your gender? Please select all that apply.

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* 24. What race do you identify with?

Accessibility
Accommodations can be provided when participating in the Caregiver Coaching Program.

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* 25. Do you require any accommodations that would make this program accessible to you?

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* 26. Do you self-identify with any of the following communities?

Thank you for completing the Caregiver Coaching Self-Referral Form! A member of the Ontario Caregiver Organization will reach out to you or the person you are registering on behalf of shortly to schedule an intake appointment. Please note, self-referrals do not guarantee a spot in the Caregiver Coaching Program. We will evaluate all referrals and direct applicants to the most suitable support available (e.g., counselling, peer support, Helpline). 

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