Hope and Healing Application

Welcome!

Through the Hope and Healing Program, we hope to address the unique challenges faced by family caregivers of older adults with dementia and a history of trauma, by providing person-centered, trauma-informed approaches and services that can help ameliorate these challenges and promote the health and well- being of this uniquely vulnerable population.

Enrollment decisions into Hope and Healing are decided on a case-to-case basis, with each individual’s specific needs, concerns, and goals taken into account. We do request that our clients meet one or more of the following criteria:

A family caregiver, aged 18 or older, of an individual impacted by trauma with dementia.
An individual impacted by trauma with dementia.

Types of trauma include, but may not be limited to: Holocaust Survivors, Abandonment, Illness, Loss and Violent Traumas, Assault, Death of a family member or friend, Injury or Illness of a Loved One, Sexual Trauma, Military Experiences, Robbery, Suicide, Witness to Violence, Accidents, Natural Disaster.

During your assessment, you will be asked to provide information pertaining to the following: Trauma history, Dementia Diagnosis history, Caregiving situation, and Referral source information.

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

For your convenience, you may complete the form below at any time and Parker’s Hope and Healing staff will contact you within 1-2 days. 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. Person with Dementia's Information

Full Name:

Mailing Address (if different than above):

Apt:

City/Town:

State:

ZIP:

Phone Number:

Question Title

* 4. Please select the best answer that describes you (check all that apply)

A caregiver of an individual impacted by trauma with dementia.

An individual impacted by trauma with dementia.

Question Title

* 5. What is the care recipient's gender?

Male

Female

Transgender

Prefer not to Answer