Please ensure that the older adult you are referring meets EACH of the below eligibility requirements. *

Check the boxes below to certify that they meet our criteria.

The older adult lives alone in San Francisco.

The older adult is 65+ years old OR The older adult is 60+ years old and is homebound or bedbound.

The older adult receives LESS THAN two social visits per month. Healthcare providers, social workers, and/or case mangers are NOT considered social visits.

In addition to meeting our eligibility requirements, older adults must be interested in participating in our social programs. Our programs are offered at no cost. *

Please check the box that applies to certify that the older adult you are referring is interested in one or more of our social programs. Again, at this time the only programs available to monolingual Cantonese and Mandarin speakers is Monolingual Visiting Volunteer and Holiday Visits.

Monolingual Visiting Volunteer - In-person, in-home visits twice a month for 6 months with a matched volunteer for monolingual Chinese-speaking older adults. This program marks our inaugural effort to offer the Visiting Volunteer program in Cantonese and Mandarin.

Visiting Volunteer - In-person, in-home visits twice a month for 6 months with a matched volunteer with the goal of creating a long-term friendship.

Saturday In-Home Visits - In-person, in-home visits with a new and different volunteer on a Saturday morning. These visits take place almost every month. During the holiday season, these will take place on Thanksgiving, Christmas Eve, and Christmas Day.

Holiday Visits - In-person, in-home visits with a volunteer on Thanksgiving, Christmas Eve, and Christmas Day.

Weekly Phone Calls - Phone calls twice a week with a matched volunteer who will provide friendly conversation and support.

Stroll Buddies - 30 minute weekly walks for 3 months with a matched volunteer in your neighborhood.

Tech Allies - Weekly in-person visits with a matched volunteer who will guide you through our curriculum and teach you how to use an iPad independently over the course of 3 months.

Creativity Connects - A 3 month long intergenerational program where you will work on a creative project with a pair of younger partners.

Muttville Cuddle Club - Spend some time with the dogs at Muttville Senior Dog Rescue on the fourth Friday of every month.

Social Gatherings - Occasional opportunities to socialize with other older adults and volunteers, often during the summer months and holiday season.

Referrer's Name *

First Name

Last Name

Referrer's Phone *

(###)

###

####

Have you informed the older adult of the referral? *

Yes

No

Older Adult's Name *

First Name

Last Name

Older Adult's Mailing Address *

We will use this address to mail the older adult an informational brochure. Please make sure it is correct!

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Older Adult's Primary Phone *

(###)

###

####

Older Adult's Additional Phone

(###)

###

####

Older Adult's Date of Birth *

MM

DD

YYYY

Older Adult's Gender Identity *

Cisgender woman

Cisgender man

Transgender woman

Transgender man

Non-binary

Not listed

Unknown

Older Adult's Mobility Status *

Ambulatory

Cane

Walker

Manual wheelchair

Electric wheelchair

Homebound

Bedbound

Unknown

Does the older adult live alone? *

Yes

No

Unknown

Does the older adult live with others? *

Yes

No

Unknown

Does the older adult live have a roommate? *

Yes

No

Unknown

Does the older adult live have a live-in caregiver? *

Yes

No

Unknown

Does the older adult have pets? *

Yes

No

Unknown

Older Adult's Living Environment *

Apartment

House

Supportive housing site

SRO

Board & care

Assisted living facility

Skilled nursing facility

Unknown

Are there any guns in the older adult's home? *

We ask this because we have volunteers going in and out of our older adult's homes.

Yes

No

Unknown

Does the older adult smoke? *

Yes

No

Unknown

What other benefits/services does the older adult receive? *

Social Security

Supplemental Social Security (SSI)

Private Pension Plan

CalFresh/EBT

Section 8 Housing (ie. housing voucher)

Medi-Cal

Medicare

In-Home Supportive Services (IHSS)

Meals on Wheels

Case Management

Intensive Case Management

Enhanced Care Management

Paratransit

VA services