Friendly Programs Client Application

ALL INFORMATION GIVEN IS CONFIDENTIAL.

This institution is an equal opportunity provide and employer, serving Contra Costa County since 1968. We are a 501(c) 3 Nonprofit Organization, IRS #68-0044205.

Are you vaccinated against Covid-19 (fully or partially)?
If no, do you plan on getting vaccinated against Covid-19?
Friendly:
If you are completing this form for another person, please include your name and number
Client Information
Do you have voicemail?
Can you send and receive text messages?
Veteran:
Do you live alone?
Live in a:
Cal-Fresh Recipient:
Emergency Contact
Hearing
Able to hear over the phone?
Vision
Memory
Memory Issues:
Medical Alert Device
Do you own a medical alert device?
Do you wear it:
Are you driving?
Are there smokers in the home?
Do you receive Meals on Wheels?
Would you like information on Meals on Wheels?
Would you like information on Fall Prevention?
Pets
Are there pets in the home?
Visit
Best days for a visit?
Best times for a visit?
Do you need assistance with:
About You
Do you enjoy:
Do you prefer a man or a woman visitor, or no preference?
Would you consider a volunteer who visits with children?
Intake Survey
How often do you feel that you lack companionship?
How often do you feel left out?
How often do you feel isolated from others?