Community-Intake-form

What would you like help with?

Select all that apply

Finding local classes, clubs, or activitiesStaying in touch with family and friendsTransportation or getting aroundFinding local senior centers or community programsVolunteering or giving backSomething else

What's on your mind right now?

Looking to stay active and try new thingsFeeling a bit more isolated than I'd likeHelping a family member who seems isolatedNot sure, just exploring

A little more about your situation

Do you currently have transportation available when you need it?

YesNoSometimes

Are there groups, activities, or programs you're already part of?

YesNo

Have any recent changes, like retirement, a move, or a health change, affected how connected you feel?

YesNoNot sure

What's your biggest concern right now?

Select all that apply

Meeting people or staying socialGetting aroundFinding the right programs or activitiesSupporting a loved oneNot sure where to start

Anything specific on your mind?

(Optional)

Support

information

Social

Stay Active. Stay Engaged. Stay Connected.

Support

information

Social