Enroll | Sourcewise

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Caring for a loved one (e.g., family member, friend, or neighbor) can be tough to navigate alone. Our team is ready to help you find a solution to realistic care and support for your loved one. Please complete the intake form below with information about you and the person you care for. This information will help us know how we can assist you. If you would like help completing this form, please call us at (408) 320-3200, option 1.

Upon completion of this intake form, you will gain access to the Sourcewise MyPlan text messages with real-time chat feature, receive 1 to 3 text messages a week with helpful information and guidance from our team straight to your phone. Text messages will come from the number 43386. We suggest saving this number as a contact in your phone with the name “Sourcewise MyPlan.” You can review the Terms and Conditions here: https://sourcewise.gomohealth.care/terms/

In addition to the text messages, you will also receive access to the Sourcewise MyPlan Library of caregiver resources, customized with resources to meet your unique needs, as well as access to text with us in real time. You will receive a welcome message from our Chat line at (833) 728-1403 – it’s a good idea to save this number in your phone as “Sourcewise Chat.”
Please take a few minutes to answer the following questions about you or the primary caregiver signing up today. We want you to know that all information shared and received in our program is confidential. Your information will not be shared or used for any other purpose.
Caregiver's Name*
First Last
Cell Phone Number*
Caregiver’s Email Address*
Caregiver Zip Code*
Please make sure that you enter a valid Zip Code to continue.
Looks like you are not eligible to continue in this program. Please click Submit to end this form.
Caregiver's Ethnicity*
(Select all that apply)
- Alaska Native
- American Indian
- Asian
- Asian Indian
- Cambodian
- Chinese
- Filipino
- Japanese
- Korean
- Laotian
- Vietnamese
- Other Asian
- Black or African American
- Hispanic or Latino
- Native Hawaiian/Other Pacific Islander
- Guamanian
- Hawaiian
- Samoan
- Other Pacific Islander
- White
- Prefer not to disclose
Language preference:*
- English
- Spanish
Caregiver’s age:*
- 18-29
- 30-39
- 40-49
- 50-59
- 60-64
- 65-69
- 70-74
- 75-79
- 80-85
- 85+
Please provide some additional information about the person you care for.
Name of the person you care for:*
First Last
How old is the person you care for?*
- 60 years old or older
- Less than 60 years old
What has the person you care for been diagnosed with?*
(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
You chose "Other", please specify:*
Is the care recipient a recipient of In-Home Supportive Services (IHSS) through Medi-Cal?*
- Yes
- No
Is your Medi-Cal through Santa Clara Family Health Plan, Kaiser, or Anthem?*
- Santa Clara Family Health Plan
- Kaiser
- Anthem
- None of the above
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
In the last 3 months, has a lack of reliable transportation kept the person you care for from medical appointments, meetings, work, or from getting things needed for daily living?*
- Yes
- No
In the last 3 months, did the person you care for ever eat less than you felt s/he should because there wasn’t enough food at home or money for food?*
- Yes
- No
How many times in the past three months did the person you care for visit an emergency room without being hospitalized?*
- 0
- 1
- 2
- 3+
How many times did the person you care for stay in a hospital overnight or longer in the past three months?*
- 0
- 1
- 2
- 3+
How many nights in total did your care recipient spend in the hospital?*
To better help you, please tell us a little bit more about how you are feeling as a caregiver:
On a scale of 1-10, how would you rate your stress level?*
Rate on a scale from 1-10, where 1 = no stress and 10 = very high stress.
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
As the primary caregiver, where does the source of your stress come from?*
- Caregiving responsibilities
- Something other than caregiving
- Both
Over the last 2 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
Do you need a break from caregiving or need respite care?*
- Yes
- No
Do you already have paid help?
- Yes
- No
Is the person helping you connected with an agency?
- Yes
- No
What is the name of the agency?
What is the telephone number of the agency?
Do you need help with Medicare or have questions on Medi-Cal eligibility?*
- Yes
- No
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 GoMo Health to contact you via text message to the number you are enrolling with from the number 43386. You may get up to 12 messages per week. 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 the 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. To unsubscribe from emails, click “unsubscribe” at the bottom of any email you receive. Terms & Conditions can be found at https://sourcewise.gomohealth.care/. GoMo Health Privacy Policy can be found here: https://gomohealth.com/privacy/.
- I have fully read and agreed to the terms and conditions of this program.
- I have completed the enrollment form, provided electronic consent to enroll, and I grant permission to GoMo Health to contact my cell phone via text message from the phone number 43386.

Sourcewise Caregivers Network MyPlan Enrollment Form

Please take a few minutes to answer the following questions about you or the primary caregiver signing up today. We want you to know that all information shared and received in our program is confidential. Your information will not be shared or used for any other purpose.

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

To better help you, please tell us a little bit more about how you are feeling as a caregiver:

Over the last 2 weeks, how often have you been bothered by the following problems?