Reassurance Application

Reassurance Program Application
Please fill each section thouroughly and to the best of your ability. You will receive an email from a HopeLine team member soon.

At this time, we are only accepting applicants who reside in North Carolina. Reassurance calls are intended to be 5-10 minute check-in calls that are social and supportive in nature. The Reassurance program is not intended to replace case management, therapy, or act as suicide watch for participants.

HopeLine does not charge a fee for this program. However, donations in any amount are greatly appreciated and go a long way to support this program.

Donations can be made online HERE or checks can be mailed to

PO Box 10490 Raleigh, NC 27605
Full Name*

First NameLast Name
E-mail*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Date of Birth

MonthDayYear
Date
How did you hear about our Reassurance Program?
Best time of day to receive a call:

Hour Minutes

AM/PM Option
Best time of day to receive a call:
Please share any interests, hobbies, church or group affiliations, etc.
Used for conversation starters with our volunteers.
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 NameLast Name
Relationship to Contact Person #1*
e.g. daughter, brother, neighbor
Phone Number for Contact Person #1*
Contact Person #2
Name of Contact Person #2*

First NameLast Name
Relationship to Contact Person #2*
e.g. daughter, brother, neighbor
Phone Number for Contact Person #2*
Additional Contacts (Optional)
Name of Additional Contact

First NameLast Name
Relationship to Additional Contact
e.g. daughter, brother, neighbor
Phone Number of Additional Contact
My submission of this forms means that I understand the following.

I understand and acknowledge that the Reassurance Program is entirely voluntary.

I understand and acknowledge that the program serves as a safety check for me. If I am unreachable after 3 attempts, the HopeLine staff will contact my emergency contact.

I understand and acknowledge that if my emergency contacts are also unreachable, emergency services will be contacted to conduct a well check.

I understand and acknowledge that if any member of the HopeLine team has knowledge or suspects abuse or neglect, they will report it to the officials in my area.

Thank you for completing the application for Reassurance Program application. You will receive a follow-up call from a HopeLine Team member within the next 7 days. Please note that we will make three attempts to contact you. If we cannot reach you, we will withdraw your application. If you have not heard from us, you can contact our office at 919-832-3326. Thank you!
Should be Empty:

Reassurance Program Application

Emergency Contacts