Reassurance Application

Reassurance Program Application
Please fill each section thouroughly and to the best of your ability. You will receive an email from our Program Coordinator within 72 hours to discuss your application.

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, but does accept donations.

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

PO Box 10490 Raleigh, NC 27605
Full Name *

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

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Date of Birth

Month Day Year
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 Name Last 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 Name Last 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 Name Last Name
Relationship to Additional Contact
e.g. daughter, brother, neighbor
Phone Number of Additional Contact
Should be Empty:

Reassurance Program Application

Emergency Contacts