SunServe Phone Tree - Client Form Survey

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1. Please provide the following (All information is confidential):

Please provide the following (All information is confidential): Name:
Address:
Address 2:
City/Town:
State:
ZIP:
Email Address:
Phone Number:

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2. Please indicate your gender:

Please indicate your gender: Male

Female

Transgender M to F

Transgender F to M

Other (please specify)

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3. How do you identify?

How do you identify? Gay

Lesbian

Bisexual

Straight

Other (please specify)

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4. Please indicate your status:

Please indicate your status: Single

Partnered

Married

Other (please specify)

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5. Please provide the following:

Please provide the following: Age:

Please list 2 local residents who can promptly visit you at home and check on your safety in the event that you do not respond to your daily phone tree contact.

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6. Please list your first emergency contact:

Please list your first emergency contact: Name:
Relationship:
Address:
Address 2:
City/Town:
State:
ZIP:
Phone Number:

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7. Does the above emergency contact have a key/access to your home?

Does the above emergency contact have a key/access to your home? Yes

No

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8. Please list your second emergency contact:

Please list your second emergency contact: Name:
Relationship:
Address:
Address 2:
City/Town:
State:
ZIP:
Phone Number:

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9. Does the above emergency contact have a key/access to your home?

Does the above emergency contact have a key/access to your home? Yes

No

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10. Do you live alone?

Do you live alone? Yes

No

If No, list Name & Relationship of person(s) living with you:

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11. Do you live in a condo or gated community?

Do you live in a condo or gated community? Yes

No

If Yes, list Apartment/Condo/Community Management name and telephone number (We must be able to contact Apartment/Condo/Community Management and have a signed consent for them to enter to check on your safety.):

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12. ************************ IMPORTANT ************************
Please check the boxes below to acknowledge each of the following statements:

************************ IMPORTANT ************************ Please check the boxes below to acknowledge each of the following statements: I acknowledge that it is my responsbility to communicate with my Phone Friend beforehand when I am not available to receive my daily Phone Friend contact

I acknowledge that after 3 calls of 45 minute intervals with no response, we will call your first line of contact to go check on you. If your first line of contact is not available, the police department will be contacted to check on your safety.

I acknowledge that SunServe WILL NOT BE RESPONSBILE for any action taken by emergency personnel.

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13. What is the safest entry into your home for emergency personnel?

What is the safest entry into your home for emergency personnel?

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14. In case of an Emergency, are there any relatives you want contacted?

In case of an Emergency, are there any relatives you want contacted? Yes

No

If Yes, please list Name, Relationship, Phone Number:

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15. What is your main reason for using this SunService? (Please indicate only one.)

What is your main reason for using this SunService? (Please indicate only one.)

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16. What level of contact are you interested in having through the SunServe Phone Tree?

What level of contact are you interested in having through the SunServe Phone Tree? Email

Text

Quick Phone Check-In

Phone Friend Conversation

Not sure

17. Please list any problems that might affect your ability to answer your daily SunServe Phone Tree:

Please list any problems that might affect your ability to answer your daily SunServe Phone Tree: Medical:
Medication:
Handicapped:
Other:

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18. Do you have a Primary Care Physician?

Do you have a Primary Care Physician? Yes

No

If Yes, indicate Name/Phone Number:

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19. Do you have a Caregiver?

Do you have a Caregiver? Yes

No

If Yes, indicate Name/Phone Number:

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20. Do you have a Case Manager?

Do you have a Case Manager? Yes

No

If Yes, indicate Name/Phone Number:

21. Which of the following do you have?

Which of the following do you have? Last Will and Testament*

Living Will*

DNR*

Power of Attorney*

*In case of emergency, where are these documents located?

Our goal is to match you up with the most appropriate volunteer. In order to accomplish this, please complete the following information:

22. Please list any other language(s) you speak:

Please list any other language(s) you speak:

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23. Are you a Florida native?

Are you a Florida native? Yes

No

If No, How long have you lived in South Florida?

24. Other than South Florida, what city/state do you call home?

Other than South Florida, what city/state do you call home?

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25. Educational background:

Educational background: None

High school

Some College

College

Major/Degree

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26. Please provide the following information:

Please provide the following information: Occupation:
Hobbies:

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27. Do you like to talk on the telephone?

Do you like to talk on the telephone? Yes

No

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28. Can you commit to making a contact with a Volunteer on a daily basis?

Can you commit to making a contact with a Volunteer on a daily basis? Yes

No

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29. What is your preferred method of communication? (Please rank 1 thru 4; 1 is best)

Face to Face

Telephone

Email

Text

_4524802684_

_4524802685_

_4524802686_

_4524802687_

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30. Check all of the following which you have/use:

Check all of the following which you have/use: Land Line

Cell Phone

Computer / Internet

Email

Text Messages

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31. Indicate your electronic comfort zone by checking all statements which are true:

Indicate your electronic comfort zone by checking all statements which are true: I search/use the internet regularly and feel comfortable filling out forms on-line.

I love email.

The computer is not my friend, but I know how to use it.

My computer gathers dust.

I use text messages, but never when I drive.

I do not text at all.

I am comfortable with all forms of electronic communication.

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32. ************************ IMPORTANT ************************
Please check the boxes below to acknowledge each of the following statements:

************************ IMPORTANT ************************ Please check the boxes below to acknowledge each of the following statements: I acknowledge that SunServe will pair Clients and Volunteers.

I acknowledge that SunServe Volunteer will develop a phone relationship with the Client as determined by the Client wants and needs.

I acknowledge the Volunteer and Client will set up their own communication schedule and how the contact will be made.

I acknowledge that I the Client, needs to communicate any problems with Volunteer directly to Senior Service Coordinator at SunServe for quick resolution.

I acknowledge that I understand that the person representing SunServe is a Volunteer and not a social worker or case manager.

I understand that the Phone A Friend program offers no direct in-home service for Clients.

I understand that if I am in immediate medical danger, I should FIRST call 911.

I acknowledget that if I am in need of any emergency assistance for Food, Clothing, and/or Rent, I will be instructed to call the 211 Broward help line.

>> Clicking Submit below indicates that you have read and understand the above statements, and that the information you have provided is true and accurate.