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)? Yes No I don't wish to answer If no, do you plan on getting vaccinated against Covid-19? Yes No I don't wish to answer Not applicable Friendly: Visitors Callers Helpers If you are completing this form for another person, please include your name and number Name Phone Client Information Application Date Last Name First Name Date of Birth Address City, State, Zip Phone Number Alternate Phone Number Do you have voicemail? Yes No Can you send and receive text messages? Yes No Preferred Language Second Language Email Veteran: Yes No Marital Status Do you live alone? Yes No If no, please state their name and their relationship with you: Live in a: Private Residence Board & Care Senior Living Facility Name of Board & Care or Senior Living Phone Number of Board & Care or Senior Living: Sex at Birth: - None -Male Female Decline to State Gender: - None -Male Female Trans Male Trans Female Genderqueer/Gender Non-binary Gender Unknown Decline to State If not listed, please specify Sexual Orientation or Sexual Identity: - None -Straight/Heterosexual Bisexual Gay/Lesbian/Same-Gender Loving Questioning/Unsure Decline to State Not listed, please specify Ethnicity: - None -Hispanic/Latino Not Hispanic/Not Latino Ethnicity Unknown Decline to State Race: - None -American Indian or Native Alaskan Asian Black/African American Native Hawaiian or Pacific Islander White Multiple Races Decline to State Unknown Please specify if not listed Approximate total monthly income Cal-Fresh Recipient: Yes No Current Support System (friends, family members, care givers, etc) Emergency Contact Name Relationship Contact Phone Email Mobility: - None -Walk independently Cane Walker Wheelchair/Bedbound Hearing Hearing Issues - None -Good Limited Hearing Aids Able to hear over the phone? Yes No Vision Vision - None -Good Limited Low Vision (describe below) If low vision, describe here: Memory Memory Issues: Yes No If yes, describe: Medical Alert Device Do you own a medical alert device? Yes No Do you wear it: Daily Often Rarely Never Other Health Issues/Conditions/Limitations: Are you driving? Yes No Are there smokers in the home? Yes No Do you receive Meals on Wheels? Yes No Would you like information on Meals on Wheels? Yes No Would you like information on Fall Prevention? Yes No Pets Are there pets in the home? Yes No How many dogs? How many cats? Other pets? Visit Best days for a visit? Sunday Monday Tuesday Wednesday Thursday Friday Saturday Best times for a visit? 10am-noon Noon-2pm 2pm-4pm After 4pm Do you need assistance with: Shopping Errands Transportation Reading Mail Other (List below) Other: About You Do you enjoy: Reading Board Games Music Card Games Movies Sports Gardening Current Events Tell us a few things you enjoy doing: Tell us a few things you like to talk about: Do you prefer a man or a woman visitor, or no preference? Man Woman No Preference Would you consider a volunteer who visits with children? Yes No Any other details to help us find a compatible volunteer for you? Intake Survey How often do you feel that you lack companionship? Hardly ever Some of the time Often How often do you feel left out? Hardly ever Some of the time Often How often do you feel isolated from others? Hardly ever Some of the time Often Submit