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
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