Senior Friend Program Intake Form

Senior Friend Program

Addressing Social Isolation of Seniors
To be placed on MultiCare’s Companion Client wait list, please complete this form to the best of your ability. When we receive your request, we will call you to confirm. Placement is based on preferences and proximity.

Senior Friends provides volunteer visits with weekly contact in-person and by phone to seniors who feel lonely. Recipients are 60 years or older and live in their own home, or with family or friends. Volunteers are matched with a senior within approximately 5 miles radius, provide weekly contact, which may include appointments, errands, food bank or senior center. Visits may also be at the client’s home or a phone call. All volunteers are screened and complete program specific training.
Name*

First NameLast Name
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Date of Birth*

MonthDayYear
Date
Gender
Ethnicity
Are you a Veteran?

YesNo
Number of people in household
Income level

$0 - $15,000$16,000 - $30,000$31,000 - $50,000$50,000 and above
Caregiver Name

First NameLast Name
Relationship to Caregiver
CAREGIVER Phone Number
Please enter a valid phone number.
If you have additional caregivers, Please list them here
Please include name, relationship and phone number for each.
Others living in home
Please include name and relationship to you for each.
Is your family involved in your life?
If we are unable to assign a Senior Friend immediately, how long do you anticipate you will be able to continue living in your current situation?

0-6 months6 months-1 year1-2 years2+ years
We are unable to place Senior Friends with clients who need to stay in bed full-time for their care needs, needs physical assistance transferring in and out of a wheelchair, or has multiple pets. Do any of these apply to you?

Need to stay in bedNeed physical assistance transferring in and out of wheelchairMore than 2 pets
If you have pets, how many and what kind?
Please help us understand your health, level of functioning, and your needs.
Can you walk unassisted?

YesNo
Do you wander?

YesNo
Can you manage your own toileting?

YesNo
Do you still cook for yourself?

YesNo
Do you use oxygen?

YesNo
Do you have any speaking impairment?

YesNo
Can you still drive?

YesNo
Do you smoke?

YesNo
Do any of these diagnosis/Needs apply to you?

Alzheimer’s diseaseChronically ill/frail elderlyLiving alone with no family supportHearing ImpairmentVision ImpairmentEmotional ImpairmentSubstance abuseShort-term disabilityRespite
Please select any personality traits that apply to you

QuietTalkativeAssertiveAggressive
Please describe your personal habits

Early riserLate riserActiveSedentary
Please select All qualities desired in a Senior Companion

MaleFemaleNo gender preferenceSmokerNon-smokerDrivesEscort me to doctorEnjoys walksExtra patience required
Please provide any other information you feel would help us make a compatible Senior Companion placement or that you think we need to know about you.
Primary Medical Clinic Name*
PRIMARY MEDICAL CLINIC Phone Number
Please enter a valid phone number.
Emergency Contact
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Referred By

Who referred you to this program?
Referrer Name
Referrer Organization
REFERRER Phone Number
Please enter a valid phone number.
REFERRER Email
example@example.com
Should be Empty:

Senior Friend Program

Please help us understand your health, level of functioning, and your needs.

Emergency Contact

Referred By