Confidential Client Information

Name:

Address:

Town: Zip

Telephone Age: ( ) Male ( ) Female

Other members of the household (if any)

Hobbies and Interests:

Major Medical Condition:

Allergies:

Emergency Contact Information:

Services requested

( ) Friendly visits ( ) Telephone Reassurance

( ) Shopping ( ) Transportation / Escort

( ) Chores ( ) Respite Care

Other:

Special Requests/Preferences___________________________________________________ _____

____________________________________________________________________________

Source of Referral:

Name:

I/We understand that this service is a volunteer effort. We release driver/ volunteer and St. Columba Church of all liability.

Client _____________________________________Date:______________

St. Columba Health Ministry Representative________________________Date:___________