AGE Y☮UR WAY SENIOR INTAKE & CONSENT PACKAGE The Loneliness ProjectKicking Loneliness in the Ass "*" indicates required fields CommentsThis field is for validation purposes and should be left unchanged.Date of Referral MM slash DD slash YYYY Referred BySelfFamilyAgencyOtherName of ReferrerPhone*Email* Relationship to SeniorSenior InformationFull NamePreferred NameDate of Birth (DD/MM/YYYY) MM slash DD slash YYYY Home Address Street Address City Province Postal Code Phone NumberEmail (optional) Emergency Contact #1NameRelationshipPhoneEmergency Contact #2 (optional)NameRelationshipPhoneHealth & Safety Information (Non-Clinical)(Used only to ensure volunteer safety & appropriate matching.)Primary LanguageSecondary Language(s)Mobility Independent Uses cane Uses walker Uses wheelchair OtherHearing 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 MatchPreferred Visit Times Morning Afternoon Evening Weekdays Weekends Preferred Visit Frequency Weekly 2 Times Per Week Twice monthly Monthly OtherPersonality 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 OtherTopics you enjoy talking aboutTopics you'd prefer to avoidHome Safety Checklist (For Volunteer Visits)Access to home Doorbell works Building entry instructions neededEnvironment 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?