Thank you for your interest in the Connections, Health, Aging & Technology (CHAT) Program ~

To help bridge the digital divide gap and address social isolation, Sourcewise is excited to offer the Connections, Health, Aging & Technology (CHAT) program.  It is free for eligible seniors and informal caregivers.  In partnership with the California Department of Aging, the program provides an iPad for limited time and training.  Devices are limited and available while supplies last.

In you are interested in the program, please fill out this brief interest survey.  If you qualify, someone from our team will contact you to set up a few research sessions before receiving your tablet.

If you’re a caregiver and would like a tablet for someone you care for (older adult 60+ years), we recommend that you do the survey process together to confirm they consent to the program enrollment and requirements.

You may contact our office at any time if you have questions or comments.  You can email us at tech@mysourcewise.com or call at (669) 699-2245.

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* 1. First Name:

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* 2. Last Name:

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* 3. Email Address (Required to coordinate sessions)

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* 4. Phone Number

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* 5. City Where You Live

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* 6. Select the Age Category That Applies:

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* 7. What language do you feel most comfortable speaking?

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* 8. What other languages are you comfortable speaking?

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* 9. An informal caregiver is defined as someone taking care of an older adult or adult with a disability."  Are you an informal caregiver?  

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* 10. Do you live alone?

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* 11. Please check any of these devices that you have in your home.  More than one answer is accepted.

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* 12. On the scale of 1 to 10 below, how comfortable are you with learning new technology?  1 is very uncomfortable; 10 is very comfortable.  Slide the circle.

0 Neutral (Neither comfortable nor uncomfortable) 10
Clear
i We adjusted the number you entered based on the slider’s scale.

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* 13. To participate in this program, you will need to participate in a total of 2 to 5 research sessions (up to 1 hour each) before and after receiving the device. This involves asking you questions over the phone. If at any time you are uncomfortable, you may decline to answer. Are you willing to participate in these sessions?

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* 14. How did you find out about this CHAT program?

We appreciate your time and interest.

The Digital Inclusion Team

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