First Name: 

Middle Name: 

Last Name: 

Street Address: 

City: 

State   Zip Code 

Home Phone Number: 

Referred By: 

Is the referred elder currently receiving services through Aging and Disability Services?
 Yes
 No

Contacts

Case Manager or Social Worker

Name: 

Organization: 

Relationship: 

Daytime Phone: 

Contact

Name: 

Relationship: 

Daytime Phone: 

Evening Phone: 

Demographic Information

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

Gender:
 Male
 Female
 Transgender
 Other

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
 Vietnamese
 Russian
 Chinese
Other: 

Veteran Status:
 Served in military
 Veteran in household
Arm of military:   Period of service 

Age: 

Birth date: 

Household Size: 

Difficulties Experienced by Participant

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 Withdrawn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 or Substance Abuse
 Hearing loss
 Chronic illness
 Complains a lot
 Incontinence
 Demanding
 Stroke
 Heart Disease
 Uses Cane
 Uses Walker
 Uses Wheelchair
 Uses Scooter
 Dementia (including Alzheimer's)
*If elder has a diagnosis of dementia, please indicate if it is mild, moderate or severe

Additional physical or mental health concerns:

Special Needs

Below are mental health and cognitive issues that ElderFriends needs to be aware of before we can make the most appropriate match with a volunteer. Please select any difficulties you know apply to the referred elder.

 Schizophrenia
 Bipolar Disorder
 Obsessive Compulsive Disorder
 Personality Disorder
 Hoarding Disorder
 Suicidal Ideation
 Developmental Disability
 Brain Injury
Other: 

What other physical/mental/emotional/cognitive issues should ElderFriends know about in order to best communicate with and support the referred elder?

Interview Questions

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

To be completed by person filling out referral form

Today's date: 

Name: 

Relationship to elder: 

Phone number: 

Email address: