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We can help. LifeCare Memory Partners is dedicated to providing caregivers of those living with dementia the education and resources to improve quality of life for all those involved.

Caregiver Intake Form

Name(Required)

First Last

Preferred Name

(what you like to be called)

Email Address(Required)

Address(Required)

Street Address City State ZIP Code

Primary Phone Number(Required)

Alternate Phone Number

What race/ethnicity best describes you? (Please choose only one.)(Required)

American Indian / Alaskan Native

Asian / Pacific Islander

Black / African American

White / Caucasian

Multiple Ethnicities / Other (please specify)

Prefer not to answer

If Other, please specify

Please choose the answer that best describe your current dementia caregiving situation.(Required)

I provide in-home care to a relative who is living with Alzheimer’s or another type of dementia

I care for my relative full-time (we live together)

I care for my relative part-time and provide intermittent care (3 times a week or less)

I provide in-home care to someone I am not related to

I am the primary caregiver

I provide care with support from siblings, in-home care professionals, or other support service

I have never used support services

I anticipate providing care to someone with Alzheimer's or another type of dementia in the near future

Please describe your current caregiving situation in 100 words or less(Required)

Call us directly. We are a resource for you.

Call Monday through Friday from
8 am – 5 pm to connect with our team.

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Caregiver Intake Form

A service of Lower Cape Fear LifeCare.