Email Address: 

First Name: 

Middle Name: 

Last Name: 

Street Address: 

City: 

State: 

Zip Code: 

Home Telephone: 

Referred By: 

Contacts

Social Worker: 

Organization: 

Relationship: 

Day Telephone: 

Contact Person: 

Relationship: 

Day Telephone: 

Evening Telephone: 

Contact Person: 

Relationship: 

Day Telephone: 

Evening Telephone: 

Primary Physician: 

Group #: 

Hospital: 

Day Telephone: 

Demographic Information

Marital Status:
 Never Married/ Partnered
 Married/ Partnered
 Divorced/ Separated
 Widowed

Gender:
 Male
 Female
 Transgender
 Other

Hispanic or Latino:
 No, not Hispanic or Latino
 Yes, Hispanic or Latino

Race:
 African American/ Black
 Asian
 Hawaiian/ Pacific Islander
 Native American
 Caucasian/ White
Other: 

Annual Income:
 Very Low Income
 Low Income
 Moderate Income
 Above Moderate Income

Languages Spoken:
 English
 Spanish
 French
 Russian
 Hebrew
 Chinese
Other: 

Age: 

Birthdate: 

Household Size: 

Below are listed several areas of physical/ mental/ emotional difficulties experienced by some older adults. Please select any difficulties you feel may apply to the referred elder.

 Withdrawn
 Depression
 Unresponsive
 Talks a lot
 Memory loss
 Gruff, crabby
 Does not go out
 Diabetic
 Vision loss
 Hypochondriac
 Alcoholism
 Hearing loss
 Chronic illness
 Complains a lot
 Incontinence
 Demanding
 Stroke

Additional physical or mental health concerns

Please ask the referred elder the following questions:

1) Do you want to have a friendly visitor twice a month?
 Yes
 No

2) What personality characteristics would you like your visiting
friend to possess?



3) What interests/activities are important for you to share with them?



4) Would you prefer a:
 Man
 Woman

 Smoker
 Non-smoker

5) Are you open to having a volunteer with a child?
 Yes
 No

Additional information you'd like to share with us