Friendly Visiting Participant/Referral Application

Friendly Visiting and Telephone Reassurance Participant/Referral Application

Thank you for your interest in our Friendly Visiting and Telephone Reassurance program. If you or someone you know is in need of support, we are here. To get started, please provide the information below and our team will be in touch with you shortly. Please note that all questions marked with an asterisk are required. We look forward to connecting!

Participant Name*
First Last
Participant Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Participant Email*
Participant Phone Number*
What is the best time to contact the participant?*
What is the best way to contact the participant?*
Are you or is the client you're referring 60 years of age or older?*
Gender*
Do you or the participant you are referring have a caregiver?*
Do we need to contact the caregiver about program participation?*
Please list the name, phone number and email of the caregiver below.
Do you have permission from the participant for the program coordinator to get in touch with them?*
Has the participant visited with or been in contact with family or friends in the past two weeks?*
Does the participant consider themselves close to family and friends or do they still feel distanced even when in their company?*
Does the participant have transportation?*
Does the participant have technology with a camera and microphone for video conferencing?*
If the participant does have it, do they know how to use it?*
Does the participant live in:*
What makes the participant a good candidate for the Friendly Visiting and Telephone Reassurance Program?*
What services would the client like to receive?*
Referral Type (Please Select One)*
Referrer Information
If other than self.
Name
First Last
Phone
Email
If you are associated or referring this client from another agency or organization, please list the name below.
Newsletter
- Yes, please subscribe me to your Newsletter.
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.

Skip links

Friendly Visiting and Telephone Reassurance Participant/Referral Application

Referrer Information