Support By Text For Caregivers Enrollment Form

Thank you for your interest in our Support By Text program for family, chosen family, and friend caregivers! To receive weekly messages with tips, resources, and events please complete this form. We hope you find this helpful in your caregiving journey.

Please complete the form below to enroll in the program. Demographic information is anonymous and helps us know who we are serving, find helpful tips, and advocate for continued funding. You may skip any optional questions that you don't want to answer.

At any time you can opt out by responding STOP to the text message or for those with a landline please follow the prompts at the end of the voicemail.

* Indicates required field

First and last name

Phone number

Type of phone number

Cell number (to receive text messages)

Landline (to receive automated voice messages)

Email address

If you don't have an email address, please enter "n/a"

ZIP code

Caregiving role

What is their relationship to you?

Please describe "Other" relationship

Age of caregiver

Gender of caregiver

Are you employed and working in addition to your caregiving role?

Yes

Language preference

Currently this program is offered in English. We are working to expand our language options.

NOTE: First name and phone number are entered into a third party platform for messaging support. All other information is for County internal use only.