Client Enrollment Application

Allies in Aging, Senior Companion Program Client Enrollment Application

Please print and complete all sections. Please answer honestly to help ensure the best match with a volunteer.
Name
Birth Date

MonthDayYear
Date
Age
Mailing Address
City
State
Zip
Phone
Cell Phone
Email
example@example.com
Do you currently experience loneliness or feelings of isolation?

NeverAlmost NeverSometimesOftenAlmost Always
Do you currently experience sadness, depression, or hopelessness?

NeverAlmost NeverSometimesOftenAlmost Always
What is the main type of service you are seeking?

Assistance with daily tasksCompanionshipAccompaniment to social activitiesAccompaniment on errandsRespite care
What is the biggest challenge you are currently facing that threatens your ability to stay in your home?
Do you require any special accommodation or have physical or medical considerations that may impact a volunteer assignment?
Do you need assistance with transportation? If so explain your needs.
What are your hobbies and interests?
Name two in-home activities you would most enjoy/appreciate.
Name two out of home activities you would most enjoy/appreciate.
What days would you prefer to have a volunteer?

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
What time of day would you prefer to have a volunteer?

MorningsAfternoons
Do you smoke?

YesNo
Do you have a pet?

YesNo
If yes what type?
Do you need physical assistance to get in or out of a car?

YesNo
Are you willing to be assigned a volunteer of the opposite sex?

YesNo
Use this space to tell us anything else we may need to know to match you with a volunteer.
Return completed application to:

Senior Companion Program Allies in Aging 1505 Avenue D. Billings, MT 59102

Angela Carter Program Manager (406) 259-3111
Should be Empty: