EmailMe Form - Volunteer Companion Program

Participant's Name *
First Last
Participant's address (for visits) - please indicate if they are living at home (alone or with caregiver), in community care, or in long-term care *
Primary Care Partner's Name *
First Last
Relationship to Participant *
Primary Care Partner's Phone # *
### - ### - ####
Primary Care Partner's email *
What type of visits do you prefer? *
In Person
Virtual (phone or video chat)
Either
Would the Participant prefer a visit from: *
A Man
A Woman
No Preference

Personal History
The following information helps us to provide a suitable and compatible match between the Participant and Volunteer Companion. In addition, this information helps the Volunteer Companion prepare for their visits by planning activities to engage the Participant during their time together.

Where was the Participant born?
Where did they go to school?
Where are the different places they lived?
Marital history (who, when, where):
Children (Names, Spouses, Locations):
Grandchildren (Names & Ages):
Siblings (Names, Locations):
Do they have any pets? If yes, please describe.
What did they do for a living?
Do/did they travel?
Hobbies & Interests (Past and Now):
Do they have any religious affiliations or other group affiliations?
Any significant awards & achievements:

Does the Participant exhibit any of the
following symptoms? Check any that apply:
Forgetfulness
Confusion
Anxiety
Apathy - absence of interest in things once enjoyed
Changes in initiative
Changes in communication
Changes in ability to perform familiar tasks
Changes in ability to problem solve
Changes in short-term memory
Changes in long-term memory
Asking repetitive questions
Changes in word finding
Changes in judgement
Changes in ability to make decisions
Restlessness
Expression of distress, fear, or frustration
Shuffled walk
Changes in balance
Decreased mobility
Sexual expressions inappropriate to time/place/person
Getting lost / losing one's way
Holding firm beliefs or experiencing sensations that may differ from how others perceive reality
Strong attachment to specific items (collecting or holding onto them)
Difficulty orienting to time, place, or person
Other
Please describe any symptoms or behaviours that are not included above.
Please make note of anything that may cause the symptoms or behaviours noted.
Please note any strategies that may help manage the symptoms or behaviours noted.
Reading

Yes No

Is the Participant able to read?

Would they like to be read to?
If yes, what type of books/magazines do they enjoy?
Does the Participant enjoy games? If yes, what are their favourite card/board games?
Does the Participant enjoy watching TV/videos? If yes, what programs do they enjoy?
What are the Participant's favourite genres of music? If they have a favourite group, please list below.
Do they play a musical instrument? If yes, what kind?
Does the Participant enjoy sports (watching or playing)? If yes, what are their favourite team(s)?
What days and times would the Participant be available to visit with the Volunteer
Companion? *
Emergency Contacts in the event the Volunteer cannot reach you during a visit:

Name Relationship Address Phone

Emergency Contact 1

Emergency Contact 2
The undersigned agrees to arrange for a responsible person to be at the home or place of residence when the volunteer arrives, and when it is time for the volunteer companion to leave. The care partner has provided alternate contacts in case of an emergency and has informed these individuals: *

Signature of Care Partner

Date

Signature of Care Partner
Date

EMF Contact Form

Report Abuse

	Yes	No
Is the Participant able to read?
Would they like to be read to?

	Name	Relationship	Address	Phone
Emergency Contact 1
Emergency Contact 2