SPEED REFERRAL

Caregiver Support Program (CGSP)

 To fill out this form over the phone, call 919-713-1556.

 Have all of your information ready before you call.

 

What This Form Is For

This form starts the referral process for the Caregiver Support Program.

The program is funded with the intention of providing products to UNPAID CAREGIVERS who are 60+ years old and are providing caregiving services for a person in Wake County who is also, 60+ years old.

To submit a referral through RFS, you must:

• Live in Wake County
• Be 60+ years or older (caregiver and care receiver)
• Caregiver must be unpaid
• Make sure to clarify the size/style, flavor, and shipping address

Important Rules

• This referral provides a caregiver with a maximum of $200 worth of caregiving supplies every 12 months.
• There are ONLY four options:

1. Incontinence: Adult Diapers

2. Incontinence: Adult Pull-Ups

3. Nutritional Beverage Supplement

4. BOTH (half Incontinence Products AND half Nutritional Beverage Supplements– $100 of each)

• The package must be shipped all at once.
• Caregivers can apply for the program every 12 months from the day they received the first shipment.
• You must provide the LAST 4 digits of the Social Security Number of BOTH the caregiver and care receiver. No exceptions.
• The person filling out the form is responsible for giving all required information. Incomplete applications will NOT be processed.
• You can fill out the form yourself, OR call 919-713-1556 for assistance
• All questions with an asterisk (*) are required.

 

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 Read the information above before starting 

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