Life Story Club Referral Form
Life Story Club is a nonprofit organization that 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 and include your email address below. Our client experience manager will follow up with a welcome call within 48 hours 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:
  • 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 *
Referring Organization Type *
Please fill out participant information below
Participant's First Name *
Participant's Last Name *
Participant's Preferred Pronouns
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Participant's Phone Number e.g. (555)-555-5555 *
Participant's Email
Participant's Date of Birth (e.g. MM/DD/YYYY) *
MM
/
DD
/
YYYY
Participant's Address
Street
City *
State
Zipcode
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
Caregiver/Home Health Aide's Last Name
Caregiver/Home Health Aide's Phone Number e.g. (555)-555-5555:
Caregiver/Home Health Aide's Email
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
A copy of your responses will be emailed to the address you provided.
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