Virtual Senior Center
Client Application
Full Name
*
First Name
Last Name
Date of Birth
*
00/00/000
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
*
example@example.com
Primary Language
*
Emergency Contact
*
Emergency Contact Relationship
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Do you have a current support system? (friends, family members, care givers, etc.)
*
Yes
No
How often do you spend time with your friends or family?
*
Daily
Weekly
Monthly
Rarely
Never
Are you active in your community? (i.e. -Senior Center, Groups, Volunteering)
*
Yes
No
If yes, how often do you participate in community events?
*
Frequently
Occasionally
Sometimes
Rarely
Never
Do you have internet access at home.
*
Yes
No
How comfortable are you using a digital service, such as a tablet?
*
Very Comfortable
Comfortable
Somewhat Comfortable
Not Comfortable
Have you ever participated in a video call? (i.e. -Facetime, Zoom, Skype, Whatsapp, etc.)
*
Frequently
Occasionally
Sometimes
Rarely
Never
Do you currently own a tablet or computer?
*
Yes
No
Do you stream movies or television at home? (i.e. -Netflix, Apple TV, Hulu, Prime Video, etc.)
*
Yes
No
How often do you feel that your lack companionship?
*
Hardly Ever
Sometimes
Often
Never
How often do you feel left out?
*
Hardly Ever
Sometimes
Often
Never
How often do you feel isolated from others?
*
Hardly Ever
Sometimes
Often
Never
Signature
*
Date
-
Month
-
Day
Year
Date
Submit
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