SunServe Phone Tree - Client Form

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

* 2. Please indicate your gender:

* 3. How do you identify?

* 4. Please indicate your status:

* 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.

* 6. Please list your first emergency contact:

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

* 8. Please list your second emergency contact:

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

* 10. Do you live alone?

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

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

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

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

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

* 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:

* 18. Do you have a Primary Care Physician?

* 19. Do you have a Caregiver?

* 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:

* 23. Are you a Florida native?

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

* 25. Educational background:

* 26. Please provide the following information:

* 27. Do you like to talk on the telephone?

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

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

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

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

* 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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