SunServe Phone Tree - Client Form

SunServe Phone Tree - Client Form

 
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1. Please provide the following (All information is confidential):
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2. Please indicate your gender:
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3. How do you identify?
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4. Please indicate your status:
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5. Please provide the following:
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:
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7. Does the above emergency contact have a key/access to your home?
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8. Please list your second emergency contact:
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9. Does the above emergency contact have a key/access to your home?
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10. Do you live alone?
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11. Do you live in a condo or gated community?
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12. ************************ IMPORTANT ************************
Please check the boxes below to acknowledge each of the following statements:
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13. 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?
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15. 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?
17. Please list any problems that might affect your ability to answer your daily SunServe Phone Tree:
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18. Do you have a Primary Care Physician?
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19. Do you have a Caregiver?
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20. Do you have a Case Manager?
21. Which of the following do you have?
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:
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23. Are you a Florida native?
24. Other than South Florida, what city/state do you call home?
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25. Educational background:
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26. Please provide the following information:
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27. Do you like to talk on the telephone?
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28. Can you commit to making a contact with a Volunteer on a daily basis?
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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:
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31. Indicate your electronic comfort zone by checking all statements which are true:
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32. ************************ IMPORTANT ************************
Please check the boxes below to acknowledge each of the following statements:
>> Clicking Submit below indicates that you have read and understand the above statements, and that the information you have provided is true and accurate.
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