Page 7 - Hospice Savannah
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    INTAKE QUESTIONNAIRE
While personal information and details are kept confidential, non-identifying information may be used for grant writing purposes. Your cooperation assists in obtaining funding that in turn allows our services to be provided at low or no cost.
Your Name: ___________________________________________________ Date: _______________ Email Address: ______________________________________________________________________ Phone: ________________________________________ Zip Code: _________________________
                                GENDER: Female ____________ Male _____________ AGE: _____________________________
  ETHNICITY
African-American _____ Asian-American _____
INCOME LEVEL
$0 - $9,999 _____ $10,000 - $14,999 _____
COUNTY of RESIDENCE
Bryan County _____ Chatham County _____ Effingham County _____
Hispanic/Latino _____ White/Caucasian _____
$15,000 - $24,999 _____ $25,000 - $34,999 _____
Native American _____ Other _____
  $35,000 - $49,999 _____ $50,000 - $74,999 _____
$75,000 and above _____
 Liberty County _____ Other County
• Who are you caregiving for? ____________________________________________ Age: _________ • Your Relationship to Care Recipient: ___________________________________________________ • Care Recipient’s Diagnosis: ___________________________________________________________ • Caregiver’s greatest concern at this time: _______________________________________________ ___________________________________________________________________________________
(please specify) _____________________

















































































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