Caregiver Application

1. Caregiver Information

Apply for the Willing Hearts, Helpful Hands Program for Family and Informal Caregivers

We recognize the important role of family and informal caregivers in supporting the health and wellness of people with Alzheimer's disease and other dementias. To get started, please fill out this application. The application will take approximately 30-45 minutes to complete.

If you have questions or need help filling out the form, you can contact us in any of these ways: Call us at 516-586-1507 or email us at WHHH@parkerinstitute.org and ask for help filling out the application.

Please remember, you will need to complete all form questions before submitting the form. After submitting the form, you’ll receive a confirmation screen.

Once your application is received, a member of the Family Caregiver Support team will contact you to discuss your application and service needs.

The information below is confidential and will help us identify the needs of those affected by dementia.

Please note that sending this form does NOT guarantee acceptance to the program. Omission of any response may result in ineligibility from services.

Question Title

* 1. Date:

Date

Question Title

* 2. Caregiver Information

Full Name:

Daytime Phone:

Address:

Apt:

City / Town

State:

ZIP Code:

Email Address:

Work Phone:

Question Title

* 3. Would you consider where you live to be…

Rural

Urban

Suburban

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* 4. Person with Dementia's Information

Full Name:

Mailing Address (if different than above):

Apt:

City/Town:

State:

ZIP:

Phone Number:

Question Title

* 5. What is the care recipients gender?

Male

Female

Transgender

Non-Binary

Other

Prefer not to answer

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* 6. Emergency Contact

Full Name:

Relationship to Care Recipient:

Address:

City/Town:

ZIP:

Email Address:

Daytime Phone:

Cell Phone: