All informational items are optional and will remain confidential. By completing this form you are helping our community develop solutions for caring for friends and neighbors with advance disease.

Group Information
Group Name:	*
City:	*
State:	Select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming *
Date Formed:	*
Facilitator Name:	*
# of Team Members:	Select... 1-5 6-10 11-15 16-20 21-25 > 25
Phone Number:
Email Address:	*
Care Receiver Information
Age:	Select...  < 21 yrs 21-35 yrs 36-55 years 56-70 yrs  > 70 yrs
Gender:	Male   Female
Race/Ethnicity:	Select... Caucasian African American Hispanic Other If other, please specify:
Caregiving Needs (diagnosis, prognosis, and/or famly situation):
Caregiver Information
Is there a primary caregiver:	Yes   No If yes, please provide the the following information:
Age:	Select...  < 21 yrs 21-35 yrs 36-55 years 56-70 yrs  > 70 yrs
Gender:	Male   Female
Race/Ethnicity:	Select... Caucasian African American Hispanic Other If other, please specify:
Relationship to care receiver:	Select... Spouse Partner Child Parent Sibling Friend Other If other, please specify:
Employment:	Select... Full-time Part-time Retired Other If other, please specify: