RSVP TeleCare Intake Form

RSVP TELECARE INTAKE FORM
We are delighted you may be interested in our outreach companionship phone calling program. Through TeleCare, our hope is to reach older adult participants who would enjoy a weekly phone call for friendly companionship.

Please fill out the form below so that we can learn more about you and partner you with a new friend. Please keep in mind this is a free service and does not include any professional help or medical advice. We simply intend to match you with someone to chat with on a weekly basis. Everybody needs a listening ear and friend to talk with often!
County - You must reside in one of the below counties to be eligible for the program*
Application Date:*

MonthDayYear
Date
Name*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Gender

MaleFemaleNon-BinaryPrefer not to answerOther
Home Phone #:*
Cell #:
Email:
example@example.com
Marital Status*

SingleMarriedDivorcedOther
Home Address*

Street

Street Line 2

CityState

Zip Code
Do you live alone?*

YesNo
If No, Name of Roommate(s):
Do you drive?*

YesNo
Do you have a car*

YesNo
Do you have pets?*

YesNo
If Yes, what kind of pets?
Do you have someone who comes in to help you on regular basis?*

YesNo
List of interests:*
Emergency Contact Person 1
Name:*
Relationship:*
Home Phone #:*
Cell #:
Work Phone #:
Emergency Contact Person 2
Name:
Relationship:
Cell #:
Cell #:
Work Phone #:
Additional Information

RSVP TeleCare will do its best to place you with a volunteer who can accommodate your schedule.
How often would you like to receive a call?*

2-3 times per weekOnce per week
What time would you like to receive the call?*
Do you prefer receiving a call from a:*

MaleFemaleNo preference
How did you hear about the TeleCare program?*
Are you a veteran?*

YesNo
If Yes, in what armed forces did you serve?
Do you have any disabilities?*

YesNo
Are you on Medicare or Medicaid?*

YesNo
Client Signature
I hereby give permission to VANTAGE Aging and RSVP to furnish this information to my assigned volunteer for purposes of the TeleCare phone call program. I understand the information provided will be used to select my assigned volunteer, and I release VANTAGE Aging and anyone obtaining/furnishing this information from any and all liability which may result from the divulgence of such information.
Client Signature

Clear
Referral

If this Telecare Intake Form is being completed on client’s behalf, please answer the following:
Referral Contact First NameLast Name
Referral Contact Phone Number:
Referral Contact Email:
example@example.com
Referal Contact Agency:
Referral Contact Relationship to Client:
Referral Signature
I am signing on behalf of my client and hereby give permission to VANTAGE Aging and RSVP to furnish this information to the assigned volunteer for purposes of the TeleCare phone call program. I attest that I have full authorization to complete this application on my client's behalf. I understand the information provided will be used to assign a volunteer, and I release VANTAGE Aging and anyone obtaining/furnishing this information from any and all liability which may result from the divulgence of such information.
Referral Signature

Clear
Please verify that you are human*
Should be Empty:

RSVP TELECARE INTAKE FORM

Emergency Contact Person 1

Emergency Contact Person 2

Additional Information

Client Signature

Referral

Referral Signature