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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.

1 Start 2 Complete

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

I am fully vaccinated against Covid-19

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 *

Month

Day

Year

Last Name *

First Name *

Date of Birth *

Month

Day

Year

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:

City, State, Zip

Sex at Birth:

Gender:

If not listed, please specify

Sexual Orientation or Sexual Identity:

Not listed, please specify

Ethnicity:

Race:

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

Address

Contact Phone

Email

Mobility:

Hearing

Hearing Issues

Able to hear over the phone?

Yes

No

Vision

Vision

If low vision, describe here:

Memory

Memory Issues:

Yes

No

If yes, describe:

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

Other:

About You

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

DONATE NOW

Help us support Contra Costa County seniors.

OUR PROGRAMS

Fall Prevention

MOW Diablo Region is a full-service organization dedicated to improving all aspects of a senior’s life.

Volunteer

Volunteer

Get involved and help local seniors stay healthy, safe, and connected to our community.

MEALS ON WHEELS

TOGETHER WE CAN DELIVER

At the core of the Meals on Wheels service is a nutritious meal, companionship and a watchful eye on the health and safety of our seniors.

For those who can still venture out into their communities, we serve in gathering places, such as senior centers and community facilities.

For those who have trouble getting around, we bring the service to you.

1300 Civic Dr.

Walnut Creek, CA 94596

Phone: 1-925-937-8311

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