Recipient Intake Form

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Personal information
  • SSI (Supplemental Security Income)SSDI (Social Security Disability Insurance)
  • CognitiveEmotionalPsychiatricPsychological Impairment(s)

  • CHF (Congestive Heart Failure)COPD (Chronic Obstructive Pulmonary Disease)Macular DegenerationMultiple SclerosisCerebral PalsyParkinson's DiseaseEpilepsyLupusRheumatoid ArthritisKidney DiseaseCancerOther (describe below)

  • CaneWalkerWheelchair (must be able to transfer/toilet independentlyOther (describe below)

  • YesNo
  • YesNo
  • YesNo
  • CigarettesPipeOther
  • You must abstain while Volunteer present.
  • YesNo
Contact information

SERVICES NEEDED:

In My Community
  • Arts Buddy   (Schedule available online or by mail - $2.50 per performance, tickets at Causeway)
  • Sports Buddy   (Volunteer to attend College or Logger sports events with you, expense of ticket)
  • Errands   
    • .
    • WeeklyEvery Other WeekMonthlyAs NeededOne Time
  • Outings  (Spending time with a volunteer out in the community doing recreational activities)
    • WeeklyEvery Other WeekMonthlyAs NeededOne Time
  • Shopping  
    • .
    • WeeklyEvery Other WeekMonthlyAs NeededOne Time
    • In StoreCarrying BagsPutting Away
In My Home
  • Bookwork (Volunteer to help sort and organize papers for payment, correspondence or filing)
    • WeeklyEvery Other WeekMonthlyAs NeededOne Time
  • Indoor Chore
    • Materials needed must be supplied or paid for by recipient. Volunteer not responsible for any cost.
      **Due to lack of volunteers, Light Housekeeping or Laundry needs can be noted, but cannot be primary need
  • Outdoor Chore
    • YesNo
    • Causeway does not allow the use gas powered tools unless volunteer and recipient assume responsibility.
  • Reading (Volunteer to read a book, newspaper, magazine, etc to a person with vision loss)
    • WeeklyEvery Other WeekMonthlyAs NeededOne Time
  • Respite (Volunteer spends time with an individual while their caregiver has time alone)
    • WeeklyEvery Other WeekMonthlyAs NeededOne Time
  • Visits (Volunteer to visit in person or on the phone, do activities with you in your home)
    • WeeklyEvery Other WeekMonthlyAs NeededOne Time
  • Writing (Volunteer to assist with personal correspondence, seasonal or occasion cards, etc)
    • WeeklyEvery Other WeekMonthlyAs NeededOne Time
Transportation
  • CarTruckSUVVan
  • City BusCounty BusTransport Service
Volunteer Matching
  • Provide any information about yourself that will help in finding a lasting volunteer match.
  • YesNo
  • captcha

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