Life Story Club Referral Form
Life Story Club facilitates small social groups for older adults to share their life stories virtually and in person to stave off loneliness and social isolation.  As the referring professional please complete the form with your email address below. A Life Story Club facilitator will reach out within one week.
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Email *
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:
  • Significant hearing loss that prevents participation in a virtual program
  • Moderate/severe dementia or Alzheimer's (mild cognitive impairment ok)
  • Severe depression, anxiety, or suicidal ideation
  • Emotional dysregulation
Referring Individual's First Name *
Referring Individual's Last Name *
Referring Organization *
Please fill out participant information below
Participant First Name *
Participant Last Name *
Participant Preferred Pronouns
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Participant Phone number e.g. (555)-555-5555 *
Participant Email
Participant Date of Birth (e.g. MM/DD/YYYY) *
MM
/
DD
/
YYYY
Participant Address
Street *
City *
State *
Zipcode *
Participant language preference: *
Is the participant living with mild cognitive impairment/mild dementia?
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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
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Caregiver/Home Health Aide First Name
Caregiver/Home Health Aide Last Name
Caregiver/Home Health Aide Phone Number e.g. (555)-555-5555:
Caregiver/Home Health Aide Email
Participant Loneliness Questionnaire
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
A copy of your responses will be emailed to the address you provided.
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