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The Loneliness Project

Kicking Senior Loneliness in the Ass

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Contact Us

(403) 510-9445

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AGE Y☮UR WAY SENIOR INTAKE & CONSENT PACKAGE

The Loneliness Project
Kicking Loneliness in the Ass

"*" indicates required fields

Comments

This field is for validation purposes and should be left unchanged.

Date of Referral

MM slash DD slash YYYY

Referred By

Name of Referrer

Phone*

Email*

Relationship to Senior

Senior Information

Full Name

Preferred Name

Date of Birth (DD/MM/YYYY)

MM slash DD slash YYYY

Home Address

Street Address City Province Postal Code

Phone Number

Email (optional)

Emergency Contact #1

Name

Relationship

Phone

Emergency Contact #2 (optional)

Name

Relationship

Phone

Health & Safety Information (Non-Clinical)

(Used only to ensure volunteer safety & appropriate matching.)

Primary Language

Secondary Language(s)

Mobility

Independent

Uses cane

Uses walker

Uses wheelchair

Other

Hearing

No difficulty

Some difficulty

Hard of hearing

Uses hearing aids

Vision

No difficulty

Some difficulty

Limited vision

Blind

Any allergies volunteers should be aware of?

Do you have pets?

No

Yes

If yes what type pet?

Do you smoke?

No

Yes (Volunteers may be sensitive to smoke)

Is there anything else we should know to ensure safe visits?

Visit Preferences & Personality Match

Preferred Visit Times

Morning

Afternoon

Evening

Weekdays

Weekends

Preferred Visit Frequency

Weekly

2 Times Per Week

Twice monthly

Monthly

Other

Personality Match Preference

Quiet and calm

Outgoing and chatty

Either is okay

Interests / Hobbies

Conversation

Cards & games

Crafts

Puzzles

Reading / books

TV/movies

Music

Walking (if safe)

History

Cooking/food

Pets

Other

Topics you enjoy talking about

Topics you'd prefer to avoid

Home Safety Checklist (For Volunteer Visits)

Access to home

Doorbell works

Building entry instructions needed

Environment

Home is safe for visits

Pathways clear

No loose carpets / tripping hazards

Adequate lighting

Pets

Friendly

Nervous/shy

Must be secured during visits

Smoking in home

No

Yes — smoking must stop during visits

Is there anything in the home that may affect volunteer comfort or safety?

The Loneliness Project

Kicking Senior Loneliness in the Ass

Get in Touch

Want to volunteer, refer a senior, or explore sponsorship? We’d love to hear from you.

Page Links

Home
Safety
Senior
Volunteer
Partners
Testimonials
FAQs
Browse Volunteers
Contact Us

Contact Information

Box 1841, Main PO
Cochrane, Alberta T4C 1B7
(403) 519-8445
info@ageyourway.ca
coordinator@ageyourway.ca

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