Adults with Aging Parents Support Group
Intake Form

Date (MM/DD/YY):

Please provide the following information and return this form to me prior to the start of our group.

Information about you, the caregiver:
Name:
Address:
Email Address:


Preferred contact number for you: Home Work Cell

Do you have siblings and if so, how are they involved?


Describe your role as a caregiver including the impact that caregiving is having on your life:


Are you currently being treated for depression, anxiety or other mental health issues? If yes, please explain:


Briefly describe the reason for wanting to join this group and any specific issues or questions you would like to address:


Information about the Elder(s):
First name(s):
Age(s):
Current location (city/state):
Living situation:
Own home
Lives with family
Skilled nursing facility
Assisted living facility
Board and care
Senior living
Other:

Medical problems (diagnoses) including hospitalizations in last 6 months:


Describe any losses or life changes your parent has had in the past 2 years:


Describe any beliefs or personality traits that make it difficult for the elder to make changes or accept help:


I understand that any recommendations made by Margo Frank LCSW are based solely on the information I provide. I agree to hold her harmless regarding the consequences of any decision I make regarding the care of named older adult(s). I agree to pay the fee for the entire group series by the end of the first session unless otherwise arranged.