Please Note: Life Story Club Exclusionary Criteria
Life Story Club is not a substitute for therapy. Participation in Life Story Club requires individuals to listen to the stories shared by other club members. LSC may be ill-suited for individuals with the following:
Moderate/severe dementia or Alzheimer's (mild cognitive impairment ok)
Severe depression, anxiety, or suicidal ideation
Emotional dysregulation
Referring Individual's First Name *
Your answer
Referring Individual's Last Name *
Your answer
Referring Organization *
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Referring Organization Type *
Please fill out participant information below
Participant's First Name *
Your answer
Participant's Last Name *
Your answer
Participant's Preferred Pronouns
Clear selection
Participant's Phone Number e.g. (555)-555-5555 *
Your answer
Participant's Email
Your answer
Participant's Date of Birth (e.g. MM/DD/YYYY) *
MM
/
DD
/
YYYY
Participant's Address
Street
Your answer
City *
Your answer
State
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Zipcode
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Participant's language preference: *
Is the participant living with mild cognitive impairment/mild dementia? *
If a caregiver would like to join Club meetings with the participant, please fill in caregiver's information below
Patient/client is eligible for Medicaid *
Caregiver/Home Health Aide's First Name
Your answer
Caregiver/Home Health Aide's Last Name
Your answer
Caregiver/Home Health Aide's Phone Number e.g. (555)-555-5555:
Your answer
Caregiver/Home Health Aide's Email
Your answer
Participant Loneliness Questionnaire (3 Question UCLA Loneliness Scale) This information helps our nonprofit to measure the effectiveness of our program. We greatly appreciate your input.
To be completed by or on behalf of prospective participant.
How often does the participant feel that they lack companionship? *
How often does the participant feel left out? *
How often does the participant feel isolated from others? *
Notes: any additional client health concerns or information
Your answer
A copy of your responses will be emailed to the address you provided.