Caregiver Wellness Initiative Application
Please complete the following application to determine eligibility for mental health counseling services.

The completion of this application does not guarantee the awarding of financial assistance from Alabama Lifespan Respite. Please note that while Alabama Lifespan Respite wishes we could help all qualified individuals who seek assistance, regrettably we only have limited funds to meet the needs of qualified caregivers. Therefore, we can only respond to requests based on our available resources.
Sign in to Google to save your progress. Learn more
Are you currently receiving respite reimbursement through Alabama Lifespan Respite? *
On a scale of 1-10, please indicate your current stress level as related to being a full-time caregiver. *
Briefly describe how/why you may benefit from mental health counseling services as a caregiver: *
If approved to receive mental health counseling services, would you be willing to complete one pre-counseling survey and one post-counseling survey online (approximately 10 minutes each) to help ALR determine the effectiveness of this program? *
How would you prefer to receive mental health counseling services? *
Do you have internet service at your residence, or access to internet service? *
Do you need a wifi-enabled tablet in order to receive mental health counseling services through Telehealth? *
If you would prefer to receive mental health counseling services in-person at a provider's office, how far are you willing to travel to receive in-person services?
Clear selection
Your Name *
Email address *
Select the Alabama county in which you reside: *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms