Recipient Intake Form

    Use the "tab" key to navigate between fields.
    Pressing "enter" or "return" submits the form.
    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

      • [time errand-time id:errand-time time-format:HH:mm]

      • [time errand-until id:errand-until time-format:HH:mm]

    • 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

    Comments are closed.