The Montgomery Borgatta Caregiver Burden Scale
The Montgomery Borgatta Caregiver Burden Scale
The Montgomery Borgatta Caregiver Burden Scale
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County of Erie<br />
Department of Senior Services<br />
Return to Nancy Schneider via mail, fax (858-6048) or e-mail.<br />
CAREGIVER REFERRAL<br />
A packet will be sent to the caregiver, including:<br />
Letter of introduction with Case Manager’s Name and phone number<br />
“Are You a <strong>Caregiver</strong>” brochure<br />
“Tips For <strong>Caregiver</strong>s“ brochure<br />
<strong>Caregiver</strong> <strong>Burden</strong> Assessment and return envelope<br />
Health Guide Record Book<br />
Magnetic Pen<br />
<strong>Caregiver</strong> Name: ___________________________________________<br />
Street: __________________________________________________<br />
City:<br />
Zip: ____________________<br />
Client Name: ______________________________________________<br />
[ ] Client has dementia - include additional brochure<br />
[ ] <strong>Caregiver</strong> is a Long Distance <strong>Caregiver</strong> - include additional brochure<br />
I have met or spoken to the <strong>Caregiver</strong> and they know the packet is in the mail.<br />
[ ] Yes [ ] No<br />
Case Manager<br />
_________________________<br />
I&R or Cluster Name<br />
___________________________
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