Enrollment - WeCare

Caregiver Name:*

First Last

Cellphone Number:*

Caregiver’s Email Address:*

Caregiver’s County of Residence:*

You chose "Other", please specify:*

Caregivers Zip Code (residence):*

Language preference:*

English
Spanish

Caregiver Age:*

Caregiver Ethnicity:*

Select all that apply

Gender

What sex was originally listed on your birth certificate?*

Male
Female
Decline to answer

Gender Identity:*

Male
Female
Transgender man/trans man
Transgender woman/trans woman
Neither exclusively male nor female (Genderqueer/gender nonconforming)
Additional gender category (or other)
Decline to answer

Please specify:*

Please provide some additional information about the person you care for.

Name of Person You Care For:*

First Last

How old is the person you care for?*

60 years old or older
Less than 60 years old

With what has the person you care for been diagnosed?*

Select all that apply

Alzheimer’s disease
Mild cognitive impairments
Traumatic brain injury
Vascular and mixed dementia
Parkinson’s disease
Huntington’s disease
Other
None

Please specify:

Hidden

Qualifier

Hidden

Qualifier3

Hidden

Qualifier2

Hidden

QVerify

Hidden

QVerify2

Hidden

QVerify3

Does the person you care for need help with any of the following?*

Select all that apply

Feeding
Dressing
Bathing
Toileting
Transferring (i.e., in and out of a chair)
Walking
None

Has the person you cared for fallen in the past three months?*

Yes
No

Do you think the person you care for may experience a fall in the next three months?*

Yes
No

To better help you, please tell us a little bit more about yourself:

On a scale of 1-10, how would you rate your stress level?*

1 = No Stress10 = Very High Stress

What is the cause of your current stress?*

Caregiving
Something other than caregiving
Both

Over the last two weeks, how often have you been bothered by the following problems?

Little interest or pleasure in doing things:*

Not at all
Several days
More than half the days
Nearly every day

Feeling down, depressed, or hopeless:*

Not at all
Several days
More than half the days
Nearly every day

Hidden

PHQ-2 Score

How confident do you feel with the level of knowledge you have about being a caregiver for your loved one?*

Are there other concerns you wish to speak to us about? If so, please note them here:

Terms and Conditions

The Telephone Consumer Protection Act generally requires us to obtain consent before contacting people on their mobile phones. By enrolling in this program, you are granting consent to Sourcewise and/or GoMo Health to contact you via text message to the number you are enrolling with from the number 43368 and 833-985-7004.

You may get up to five messages per week. Text messages may include health care information related to your condition, your loved one’s condition and the care/services offered through the WeCare program. Please note that depending on your mobile phone service plan, message and data rates may apply according to your mobile provider.

You also confirm that you are the wireless subscriber or owner of the mobile number provided and have authority to provide consent. For help, please text HELP to 43386. You may opt-out at any time by replying STOP or STOPALL to 43386.

Terms & Conditions can be found at https://wecare.gomohealth.care/. GoMo Health Privacy Policy can be found here

Terms and Conditions*

I have fully read and agreed to the HIPAA disclosure and terms and conditions of this program.
I have completed the enrollment form, provided electronic consent to enroll and grant permission to Sourcewise and/or GoMo Health to contact my cell phone via text message from the phone number 43386 and 833-985-7004.

WeCare

Sign-Up Form

Terms and Conditions