Reassurance Application

Reassurance Program Participant Application
HopeLine's Reassurance Call Program enables volunteers and staff to make daily calls to individuals with little or no daily contact with others. These daily calls provide reassurance and a reminder that there is a compassionate person who cares and is willing to listen. Our crisis counselors have access to the participant's emergency contact(s). The purpose of this program is to reduce isolation, increase access to community resources, and to provide a greater peace of mind to participants and their loved ones in efforts to allow participants to continue to live independently.

This program is free of charge, and anyone can sign up at any time regardless of age or ability status.

Individuals interested in being our program may fill out the application below, download a Microsoft Word version from our website under "Programs", or reach out to HopeLine's office to speak with the Program Coordinator at 919-832-3326 or programs@hopeline-nc.org
Full Name *

First Name Last Name
E-mail
Phone Number *

Area Code Phone Number

Address *

Date of Birth

Month Day Year
Date
How did you hear about our Reassurance Program?
Best time to call
Interests, hobbies, church or group affiliations, etc.
Are there any health concerns that you would like HopeLine to be aware of?
Emergency Contacts

In order to be enrolled in our Reassurance Program, you must have at least two emergency contacts on file with our organization. These emergency contacts will be contacted in the event that we are unable to get in contact with you for three consecutive days.
Contact Person #1
Name of Contact Person #1 *

First Name Last Name
Relationship to Contact Person #1 *
e.g. daughter, brother, neighbor
Phone Number for Contact Person #1 *

Area Code Phone Number
Contact Person #2
Name of Contact Person #2 *

First Name Last Name
Relationship to Contact Person #2 *
e.g. daughter, brother, neighbor
Phone Number for Contact Person #2 *

Area Code Phone Number
Additional Contacts (Optional)
Name of Additional Contact

First Name Last Name
Relationship to Additional Contact
e.g. daughter, brother, neighbor
Phone Number of Additional Contact

Area Code Phone Number
Should be Empty:

Reassurance Program Participant Application