Senior Programs Information Form

Senior Programs Information Form

First Name:

Middle Name or Initial:

Last Name:

Street Address:

Apartment/Suite #:

City:

Zip Code:

Phone Number:

Email:

FAX:

County:

Referral Source:

Rehab Facility Transportation:

Rehab Facility Counseling:

Degree of Visual Impairment:

Vision Loss Onset:

Visual Impairment Cause:

Communication Preference:

Braille

Electronic

Large Print

Standard Print

Verbal

Primary Language:

If "Other" primary language, please state:

Veteran:

Race:

Ethnicity: Examples include but are not limited to "Italian, Spanish, Mexican, French, Polish, Chinese, Japanese, German..."

Gender:

Date of Birth:

Living Arrangement:

Living Arrangement Satisfaction:

Housing Locale:

Type of Residence:

Other Living Information:

Number of People in Household:

Emergency Contact Name:

Emergency Contact Phone:

Emergency Contact Relationship to Client:

If "Other", state your title and role:

Primary Medical Benefit:

If "Other", please give information:

Primary Source of Income:

Annual Income:

Estimated Annual Income:

Non Visual Impairments:

Addiction Disorder

Anxiety

Asthma

Cancer

Cardiovascular

Cerebral Palsy

Cerebrovascular (Stroke, Other)

Cognitive Impairment

Depression

Developmental

Diabetes

Emotional Disabilities

Epilepsy

Hearing Impairment

Hypertension

Learning Disabilities

Mental Health

Musculoskelatal

Neurological Impairments/Disorders

Orthopedic

Paralysis

Pulmonary

Renal Disease

Tuberculosis

TBI

Autism Spectrum Disorder

Dialysis Patient

Other:

Age Related Impairments:

Hearing

Diabetes

Cardiovascular

Cancer

Bone, Muscle, Skin, Joint Disorders

Alzeimers Disease

Depression/Mood Disorder

Other Major Geriatric Concerns:

Two or More Conditions:

Other Important Notes:

Mobility Aids:

If "Other", which type(s) and name(s) of mobility aids:

Education Level:

Employment Status: